Americans are fighting about health care — again. Here's why

How Americans get their health care is one of the most enduring, and partisan, debates in U.S. politics. Republicans are finally in a position to repeal Obamacare, but it's turning out to be more difficult than they expected.

Trump, Republicans vowed to replace Obamacare but find it's easier said than done

Speaker Paul Ryan, centre, introduced the American Health Care Act in the House of Representatives on March 6, 2017. (Susan Walsh/Associated Press)

As Republicans in the U.S. Congress were working on a bill last month to replace the Affordable Care Act, more popularly known as Obamacare, President Donald Trump made a dubious claim: "Nobody knew health care could be so complicated."

Maybe a rookie like Trump didn't know, but health care reform has been one of the most enduring and bitter battles in American politics.

President Barack Obama and the Democrat-controlled Congress passed the ACA in 2010. Republicans challenged Obamacare with many legal battles and repeated unsuccessful attempts to repeal it.

Trump and the Republicans campaigned on replacing Obamacare with something that would give Americans more choices in their health care coverage, and they promised it would be better care for less money.

On March 6, they unveiled their long-awaited plan on how to accomplish those goals, and now the U.S. is seized, yet again, with a fight over health care. 

Here are some key questions and answers to get you up to speed on the debate south of the border.

What is the replacement plan called?

The bill is called the American Health Care Act, which some opponents are calling Trumpcare. Others are referring to it as "Ryancare" because it was introduced in the House of Representatives by Speaker Paul Ryan. It's also been dubbed "Obamacare Lite" by some conservatives who aren't happy with it.

Let's go with Trumpcare. How does it compare to Obamacare?

One of the key differences is that it scraps what is known as the individual mandate — the requirement for every adult American to take out health insurance or pay a fine. It also lifts the requirement for large companies to offer insurance to their employees. 

Obamacare expanded Medicaid, the publicly funded health insurance system that helps lower-income people get care. Trumpcare rolls back the expansions.

Trumpcare keeps some parts of Obamacare but modifies them. It still offers tax credits to help people pay for plans, for example, but changes the eligibility. While the Obamacare tax credits are based on income, the Trumpcare ones will be tied mostly to age.

Trumpcare also retains two popular provisions of Obamacare: the one that allows children to stay on their parents' plan until age 26 and the one that bans denying coverage to people with pre-existing conditions.

What's the debate about?

Democrats say the proposed Obamacare replacement "couldn't be worse," according to House minority leader Nancy Pelosi. 

They say it will make insurance more expensive; that it will lead to millions of people losing their plans; and that it will harm women's health because it cuts off all federal funding to Planned Parenthood, which provides health care in addition to abortions. (U.S. law already dictates that current funding for Planned Parenthood may not be used toward abortions.)

Senate Democratic leader Chuck Schumer and House Democratic leader Nancy Pelosi have slammed the Republican plan to replace Obamacare. (Kevin Lamarque/Reuters)

Democrats aren't the only ones critical of the replacement plan — some Republicans don't like it either, but they aren't united in their opposition. Senator Rand Paul, of Kentucky, is one of the bill's loudest critics. He and others have said it doesn't go far enough and they won't vote for it in its current form.

Other Republicans are worried about their constituents losing coverage, and are at odds with the Paul faction over funding of Medicaid. Some members of Congress have faced angry voters at town halls who are concerned about how they will be affected by the new plan.

At the most basic level, the debate boils down to how much should the government be involved in how Americans get their health care.

Will it pass?

If Republicans who oppose the plan join with Democrats, who will certainly vote against it, the AHCA could fail — and that would be embarrassing to the Trump administration. That's why the White House, Ryan and others are working hard to sell the plan and negotiate with fellow Republicans to ensure they will get behind it.

What's at stake?

The 2018 mid-term elections are already just around the corner, and Republicans risk losing their majority in Congress. Ryan has warned there will be "a bloodbath" for his party if they don't come through for their voters. 

Will Americans lose their coverage or not under Trumpcare?

That's what a lot of Americans are wondering, too. Obamacare, through its various provisions, meant an estimated 20 million more Americans now have coverage who did not have it before. The Republican plan to rollback Medicaid will surely mean fewer lower-income people getting care.

The other big concern is the scrapping of the individual mandate. For Obamacare — and, indeed, any large insurance scheme — to stay afloat requires young, healthy people to buy in, to offset the costs of sick and older people.

Supporters of the Affordable Care Act demonstrate in Colorado on Jan. 31, 2017, against a bill at the state level that would chip away at Obamacare. (Brennan Linsley/Associated Press)

If they aren't forced to, healthy people may choose not to buy insurance or pull out of their plans, which drives up costs for those who remain. That could make it unaffordable for some, who may then forgo their coverage. And so on.

At his nomination hearing, Health Secretary Tom Price said it is "imperative" that those who have health coverage are able to keep it. On Sunday, Price also said in an interview that "nobody will be worse off financially." Democrats disagree.

Paul Ryan acknowledged the AHCA could mean fewer Americans with health insurance — and that's the whole point. "It's up to the people," he told CBS's Face the Nation. People shouldn't be forced by the government to buy health insurance if they don't want it, he said.

The nonpartisan Congressional Budget Office released its review of the bill Monday. The CBO estimates that 14 million more people would be uninsured in 2018 and 24 million more in 2026 if the plan is adopted. It also estimated that the plan would reduce federal deficits by $337 billion US in the 2017-2026 period. 

The White House pre-emptively cast doubt on the office's ability to provide accurate estimates.

Americans, meanwhile, are left trying to sort out who to believe.


Meagan Fitzpatrick is a multi-platform reporter with CBC in Toronto. She previously worked in CBC's Washington bureau and covered the 2016 election. Prior to heading south of the border Meagan worked in CBC's Parliament Hill bureau. She has also reported for CBC from Hong Kong. Follow her on Twitter @fitz_meagan


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