The Asclepius Initiative Policy Briefs
What Happens if the Affordable Care Act (Obamacare) Goes Away?
President Donald Trump has vowed to make significant changes to the Affordable Care Act (ACA), also known as Obamacare. While it is unlikely to be repealed, some of the changes that have been proposed could significantly weaken the law and harm the people who currently are insured through their employer, the Marketplace, or Medicaid.
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Background
The ACA went into effect in 2014. In 2013, roughly 44 million people in the United States were uninsured. As of 2023, there were 25.3 million people who were uninsured in the U.S., which represents 9.5% of the U.S. population, an historic low. Reasons for lack of insurance coverage include the high cost of insurance for people with low-income despite subsidies, lack of Medicaid expansion to people with low-income in some states, undocumented status, and lack of access to the health care exchanges.
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Effects of Repeal
If the ACA is repealed, 29.8 million people could lose their health insurance coverage, more than doubling the number of people without insurance. In Kentucky, it could mean the number of uninsured people in the state would increase by 486,000 people (200%). In addition, because people would have less discretionary income due to higher out-of-pocket costs for medical care, there may be less spending on groceries, etc., and a projected loss of 2.9% of jobs in Kentucky.
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Prior to implementation of the ACA, nearly 20% of people applying for individual insurance were denied coverage; some insurers had denial rates of over 40% or more. It is estimated that as many as 133 million people with pre-existing conditions could lose protection if the ACA is repealed and could possibly be denied coverage altogether. Under the ACA, children have been allowed to remain on their parents’ insurance until age 26, a benefit that could also be lost, resulting in more young people without insurance coverage.
Without access to health insurance, people may be forced to choose between medications, doctor’s visits, and feeding their families. Many more may delay or avoid care, which will most certainly result in worsened health care outcomes.
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In addition to poor individual health outcomes and worsened individual and community financial stability if Obamacare is repealed, the health care system also is likely to suffer. It is estimated that hospitals would receive $600 billion less, and funding for such services as outpatient medical care would fall by $1.1 trillion if the ACA is repealed, while demand for uncompensated care will rise. This could result in significant stresses on hospitals and practices. Rural hospitals already face financial challenges and could be left at greater risk of closure, worsening access to timely medical care for the communities they serve.
Conclusion
In summary, the ACA has provided more people with access to affordable care, especially in those states that chose to expand Medicaid, including Kentucky. Dismantling it without a better replacement would result in tens or even hundreds of millions of people lacking access to health care coverage, with resulting declines in their personal health and financial security, as well as destabilizing the health care system, particularly in rural and underserved areas.
What Is Socialized Medicine?
Socialized medicine is a term that can sound scary, but let's understand what it really means.
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In 1945, President Harry S. Truman wanted to create a National Health Act to give health insurance to all Americans, like in some European countries. But Congress didn’t agree. This plan was similar to today’s Medicare and Medicaid programs.
Doctors and the American Medical Association (AMA) opposed it because it would limit how much doctors could charge. The AMA started a campaign to make people afraid of the idea, calling it “socialized medicine” to make it sound like communism. Their ads and articles in newspapers scared people, and the plan failed.
Today, the term “socialized medicine” is still used to make people dislike the idea of universal health care. But many rich countries like the UK, Canada, Germany, and Japan provide health care for everyone, and they have better health outcomes and more doctors per person than the U.S. Some say the UK has true socialized medicine because the government owns hospitals and employs doctors. Other countries use private insurance and independent doctors.
Socialized medicine isn’t the same as socialism or communism. The U.S. already has public services like schools, parks, and libraries, which doesn’t make it a socialist country. For many years, people have been convinced that health care coverage should come from employers. But imagine if schools or parks were only available through jobs – many people would miss out on activities that add to quality of life. In a way, the U.S. Department of Veterans Affairs (VA) already provides a form of socialized medicine, where veterans get free healthcare from government-employed doctors.
So, don’t be scared by the term “socialized medicine.” More coverage for more people means a healthier USA.
1. Poen, M.M. (1979) Harry S. Truman versus the Medical Lobby: The Genesis of Medicare. University of Missouri Press.
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The Impact of Increased Access to Health Care Coverage
People with health insurance coverage have better health and better medical outcomes than those who do not have insurance. When people have health insurance, they are more likely to use health care services and have better overall health. People with coverage are more likely to use preventive services (like getting an annual checkup or having a mammogram or prostate exam). They are more likely to have better quality health care, get the right diagnosis for health conditions, and use medications to help improve their health. This leads to fewer emergency visits and hospitalizations. When people have coverage, they are also less likely to have depression and are more likely to say they are in “good” health.
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On the other side, people without insurance have worse health outcomes than those who are insured. When people don’t have insurance, they often aren’t able to access health care due to the high costs. People without insurance have limited access to resources, which increases the risk of bad health outcomes. People without insurance are more likely to wait to see the doctor when they need to, which means they are more likely to be hospitalized. In addition, they may wait longer to go to the hospital, are sicker when they get there, and this can result in poorer outcomes. They are also less likely to have regular checkups, cancer screenings, and diabetes care. This means their overall health is more likely to suffer.
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People without insurance often have lower incomes, are minorities, and/or live in rural areas. Health insurance reform has had the biggest impact on improving the health of people who are low income, minorities, elderly adults, and women. Many states have not expanded Medicaid, which means many people with lower incomes do not have a way to pay for their health care. This can make it harder to manage chronic diseases. People from rural areas have been affected the most because rural areas have difficulty keeping health care professionals in the area and keeping health care services. Access to health care can often depend on where people live, how much they earn, and whether they have health insurance.
Ozempic (Semiglutide) – A Case Study of a Broken Healthcare System
A universal health care system could be of significant benefit in the reduction of obesity and diabetes.
According to the Trust for American Health, approximately 41.9% or 110.1 million adults are overweight/obese in the US. Obesity contributes to many health problems, including Type 2 Diabetes, high blood pressure, heart disease, cancer, and arthritis. In the past, there were limited options for treating obesity. Many of the medications had unacceptable side effects and could not be taken for a long period of time. Weight loss programs such as Weight Watchers™ had some limited success, but even if people were successful in losing weight, they often regained much of it over time.
A new class of diabetes medications, GLP-1 inhibitors, have been shown to cause significant weight loss, even in people who do not have diabetes. The demand for these drugs has exploded, as has the cost for the drugs, often making it impossible for people to be treated with them. Novo Nordisk, which makes the GLP-1 inhibitors Ozempic and Wegovy, has made record profits – $23.6 billion in revenue in the first nine months of 2023, with 52% of this revenue coming from Ozempic and Wegovy alone.
The current cost of a month’s supply of Ozempic in the U.S. is $936 while it is $103 in Germany and $83 in France. Many insurance companies have refused to cover the cost of these medications, which has put treatment out of reach for millions of people.
Donna (not her real name) is 38 years old and has been obese for most of her adult life. She is working but has minimal insurance through her employer. After a recent trip to the ER for a kidney infection, she was diagnosed with Type 2 diabetes, high blood pressure, and fatty liver. She was given a prescription for medications for her diabetes and high blood pressure and was told that she needed to lose weight or she could end up with liver failure and, eventually, kidney failure. Her insurance refused to cover medications that would treat her diabetes and help with weight loss due to the cost, even though it could be cost-effective in the long run to prevent those problems in people like Donna.
Even if the insurance company knows that treating people with an expensive drug might reduce the costs associated with complications related to obesity, they may still be reluctant to cover the medication. This is because there is a reasonable chance that the people who need the medicine will no longer be on their insurance plan by the time they experience the future consequences of their obesity. The insurance company can save money in the short run by refusing to cover the weight loss drugs while deferring the medical and financial costs of obesity into the future – and hopefully to another insurance carrier.
A universal healthcare coverage system could help in situations like this by eliminating the incentive to push costs down the road. Another benefit would be the ability to negotiate prices with the drug companies so that they receive fair payment for drug research and development while allowing people access to lifesaving and life-enhancing medications. In addition, if people were covered from “cradle to grave” by a single-payer system, their long-term health would be taken into account when deciding how best to deliver the right treatment at the right time.
Navigating Health Care Coverage
Health care coverage is crucial because it helps fund the high cost of care when you're sick or injured. Even if you're healthy now, unexpected accidents or illnesses can happen... and drain your savings. Health insurance works by pooling money from many people so that those who need medical care can afford it.
Understanding your health insurance options can be complicated, but it's essential. You might have different choices depending on factors like your age, income, and where you live. When choosing a plan, it's not just about the monthly premium you pay. Before you decide, take time to look into copays, deductibles, and what services are covered.
Once you have health insurance, knowing how to use it effectively is key. You might have to pay a deductible before some of your coverage kicks in. Preventive care, like check-ups and screenings, is often covered without additional costs such as copays or deductibles. Understanding the paperwork your insurance sends you is important, too – read it carefully and keep records of everything.
Sometimes, insurance companies deny coverage for treatments or services. If this happens, you have the right to appeal their decisions. Your doctor’s office may be able to assist you in the process. If you're still having trouble, the Kentucky Department of Insurance might be able to help you.
Understanding your health insurance and knowing how to navigate it is crucial for your well-being. If you're unsure about anything, don't hesitate to ask for help from trusted sources.
Explore Your Options for 2025 Medicare Open Enrollment
If you have Medicare or a Medicare Advantage plan, now is the time to explore your options. Medicare open enrollment for 2025 runs from October 15, 2024, through December 7, 2024. During this time, you can make changes to your coverage. In 2025, prescription drug plans are required to cap your cost for covered drugs at $2,000 a year, so you should look at your options before deciding whether or not to keep your existing plan.
Let’s look at your options. During Medicare Open Enrollment you can:
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Keep your existing plans - but see below for changes that may affect your coverage.
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Change from Medicare Advantage (sometimes called Part C) to Traditional Medicare (you can also do this during Medicare Advantage open enrollment from January 1, 2025 to March 31, 2025).
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Change from Traditional Medicare to a Medicare Advantage plan. (For more information about the advantages and disadvantages of Traditional Medicare vs. Medicare Advantage, click here.)
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Change Medicare Advantage plans (you can also do this during Medicare Advantage open enrollment from January 1, 2025 to March 31, 2025).
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Enroll in a Medicare Prescription Drug plan (also known as a Part D plan) if you have or are changing to Traditional Medicare.
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Change or cancel your Medicare Prescription Drug plan.
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Enroll in or change a Medicare Supplement plan (also known as a Medigap plan) if you have or are changing to Traditional Medicare. Be careful. If you’ve had Traditional Medicare for over 6 months, enrolling in a Medicare Supplement plan may require a physical exam. If you have certain health conditions the cost may be higher, or you can even be denied coverage if you are beyond the one time only six month Medigap enrollment period. For more information, see https://www.medicare.gov/health-drug-plans/medigap/ready-to-buy/when
No matter what you decide to do, even if you decide to keep your existing plan(s), there are some important things to consider.
If you have a Medicare prescription drug plan (also known as a Part D plan) or a Medicare Advantage plan with drug coverage, your plan will likely change because of the new $2000 cap on your out-of-pocket cost for covered drugs.
You should have received an “Annual Notice of Change” document describing coverage changes from your prescription drug plan. Review these changes carefully. Your monthly premium (the amount you pay each month) and your deductible (the amount you pay each year for drugs before your plan starts to pay for drug costs) may change.
More importantly, one or more of the drugs you currently take or should be taking may or may not be covered in 2025.
Because the $2,000 cap only applies to covered drugs, it’s important to make sure that any drugs you take, or drugs your provider wants you to take, will still be covered by your plan. Your plan has a list of covered drugs called a formulary. Check your plan website or call the number on the back of your card to learn about changes to the formulary for 2025.
To see and compare plans available to you, go to https://www.medicare.gov/plan-compare/#/?lang=en&year=2025
Enter your ZIP code, and you’ll be able to compare the plans for all the drugs you take at different pharmacies in your area.
Do you need more information about how to proceed?
Understanding the various options and how they affect you is complicated. In Kentucky, seniors and people with disabilities can get additional help at https://www.chfs.ky.gov/agencies/dail/Pages/ship.aspx
Outside Kentucky, see https://www.shiphelp.org
Suicide and Access to Mental Health Services in Kentucky
Suicide is a serious issue in the United States, affecting people of all ages and backgrounds. Between 2000 and 2021, suicide rates increased by 36%, with youth, people of color, and rural populations experiencing the fastest rise. In Kentucky, suicide rates were above the national average in 2021, particularly through firearm use. Depression, anxiety, and substance abuse rates are also higher in Kentucky, contributing to the risk of suicide.
Suicide is linked to various factors, such as mental illness, previous suicide attempts, physical health issues, legal and financial problems, substance use, adverse childhood experiences, and relationship stressors. Protective factors include healthy relationships, access to mental health care, coping skills, and community support.
Recognizing warning signs is crucial for early intervention, and the 988 Suicide and Crisis Lifeline is a valuable resource for immediate help. However, accessing mental health treatment in Kentucky, especially in rural areas, is challenging due to shortages of healthcare professionals. Telemedicine can help bridge this gap, but issues like insurance coverage and internet access need to be addressed.
Barriers to mental health treatment include being uninsured or underinsured. Medicaid expansion has proven beneficial in reducing suicide rates, emphasizing the importance of maintaining expanded Medicaid services in Kentucky. Privately insured individuals with mental illness often face high out-of-pocket costs and limited provider availability.
Minority populations in Kentucky encounter higher barriers to mental healthcare, and efforts are needed to address these disparities. In 2020, suicide rates among Black Kentuckians increased significantly, emphasizing the need for targeted mental health intervention.
To address the rising suicide rate in Kentucky, it is essential to advocate for sufficient mental health resources, recruit more providers to rural areas, improve telemedicine availability, and ensure equitable healthcare coverage for mental health services for all Kentuckians.
Medicare Advantage vs. Traditional Medicare
Medicare is a government program that helps older people and some younger folks with disabilities get healthcare. There are two main ways to get Medicare coverage: Traditional Medicare and Medicare Advantage.
Traditional Medicare is like a big group plan for everyone who qualifies. People pay monthly fees, and it helps cover doctors and hospitals all over the country. Sometimes, though, there are extra costs that people need to pay, including portions of care not fully covered by Medicare, including prescription drugs. Some folks also buy so- called "Medigap" and “Part D” policies to help with these extra costs.
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Medicare Advantage is a bit different. It's like joining a special club run by private insurance companies. They have their own rules about which doctors and hospitals you can use, and they might say no to certain tests or treatments. They can offer extra things like dental or vision care, which Traditional Medicare doesn't cover.
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In recent years, more and more people have been picking Medicare Advantage because of these extra benefits. It's become popular, with almost half of all Medicare recipients choosing it in 2022. It’s profitable for the insurance companies, costing the government $321 more per person compared to traditional Medicare in 2019. That's why insurance companies advertise it a lot. Some people say we should make Medicare better instead of giving insurance companies so much money.
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In the end, whether you choose Traditional Medicare or Medicare Advantage depends on what's most important to you. Traditional Medicare gives you more freedom to pick your doctors and other healthcare providers and has fewer restrictions on coverage for tests and treatments ordered by your doctors. Medicare Advantage has extra perks, but more restrictions on care. And there's ongoing debate about which one is better for everyone.
Medicaid Coverage Post-Pandemic
Medicaid is a program that helps low-income people get medical care. It started in 1965 helping low-income children, pregnant women, and older adults. In 2010, the Affordable Care Act (ACA) allowed states to make Medicaid available to more people. In the states that agreed, adults between 19 and 64 with incomes below 138% of the poverty level and pregnant women with incomes below 200% of the poverty level could join Medicaid. Now, 40 states and the District of Columbia have expanded Medicaid, but 10 states haven't.
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Kentucky expanded Medicaid in 2014, covering around 1.5 million residents, or one in three Kentuckians, prior to the COVID-19 pandemic. During the pandemic, a law was passed to allow people to stay on Medicaid without the need for requalification, recognizing the economic challenges brought about by COVID-19.
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However, as of April 30, 2023, the rule suspending requalification checks ended. Some states have already started removing people from Medicaid, even if they remain eligible. It is estimated that as many as 15 million people, including 5 million children, are at risk of losing Medicaid coverage. In Kentucky, 250,000 people are at risk for losing Medicaid coverage.
Expanding Medicaid during the pandemic significantly increased health coverage. Discontinuing continuous Medicaid enrollment is expected to raise the number of uninsured individuals, posing risks to public health and hospital finances.
For more information, see Kentucky Voices for Health Medicaid Renewals Explainer. At the end of the day, a better system would be one in which everyone has health care from birth to death, improving health and helping hospitals avoid losses from unpaid care.
The U.S. vs. the World
Healthcare in the United States is the most expensive in the world. Many Americans have coverage through private insurance while others have Medicare or Medicaid coverage through the government. Nearly 30 million Americans have no insurance at all.
When you think of health insurance in the U.S., you think about coverage provided through an employer. The employer pays a larger share of the cost and the employee may pay a smaller amount. When the employee needs to see a doctor, get medication, or receive hospital or emergency care, they may pay additional amounts through what are called deductibles and co-payments. What you may not know is that this form of coverage is unique to the U.S.
Not every employer is required to provide insurance coverage. The U.S. is the only rich country in the world that doesn’t guarantee health care coverage for everyone. The Affordable Care Act of 2010 increased access to coverage, but in 2022, more than 12% of adults 18-64 in the U.S. were uninsured. An additional 20% of Americans lose coverage temporarily, such as when changing jobs.
In contrast to the U.S., governments in wealthy countries including Canada, Norway, Germany, and England all provide basic health insurance for all residents. Private insurance is available in many of those countries, but each of them share the goal for all residents to have access to healthcare regardless of their ability to pay. Switzerland’s healthcare system is the closest to that of the U.S., using a combination of private coverage and public coverage from the government. However, everyone in Switzerland has basic healthcare coverage and employers do not provide health coverage except for accident-related workman’s compensation.
In each of these 5 other countries, people live an average of 3.67 years longer than they do in the U.S. and the yearly cost of healthcare is about 46% less per person than in the U.S.
Providing healthcare for everyone is no different than providing public libraries, a police force, or fire department.