Update From Washington

Joshua A. Hirsch MD FACR, FSIR, FSNIS is Vice President of ASNR and a senior affiliate research fellow at the Neiman Health Policy Institute. This material in this comment is adapted from an recently published article. Citation below (or at end of the electronic comment).

Hirsch JA, Leslie-Mazwi T, Nicola GN, Milburn J, Kirsch C, Rosman DA, Gilligan C, Manchikanti L. Storm rising! The Obamacare exchanges will catalyze change: why physicians need to pay attention to the weather. J Neurointerv Surg. 2018 Oct 29. pii: neurintsurg-2018-014412. doi: 10.1136/neurintsurg-2018-014412. [Epub ahead of print] No abstract available.

PMID: 30373811

In 2010, almost fifty million Americans had no form of medical insurance. The drafters of the ACA utilized two main strategies to change that; Medicaid Expansion and Healthcare Exchanges. The ACA expanded Medicaid such that states that participated in the program were required to extend coverage to 133% of the poverty line.   The Obamacare Health Exchanges were online markets for purchasing health insurance. In 2013, the administration estimated that there would be up to 29 million people enrolled in the exchanges by 2019. This projection proved wildly optimistic. Early on, as the Marketplaces became active, issues such as the high cost for relatively healthy young adults and narrow networks for beneficiaries were raised.


President Trump was not likely the first to state but was perhaps the most prominent person to note “Obamacare is imploding” on his Twitter account. What reason did people cite for making this statement? As outlined earlier, a critical component of the ACA was the development of Healthcare Exchanges; in essence “marketplaces” where individuals could purchase what was to be “affordable” insurance. The cost of insuring people through Exchanges has increased dramatically since the inception of the ACA. For most of the Exchange beneficiaries, this is an invisible cost funded in large part by the US taxpayer. This explains how the market can sustain up to triple digit rate increases in various locales. For those that are not benefiting from this benefit or other subsidy, (i.e. enrollees with income over 400% of the federal poverty line) the costs can be prohibitive. In these groups, enrollment is diminishing. The challenges to this population, unsubsidized beneficiaries on the Exchanges, is a main rationale for the argument that Obamacare is unsustainable.


Since passage of the ACA, Republicans have utilized its provisions to mobilize their base. In 2017, congressional Republicans tried to make good on their promise to “repeal and replace.” In the wake of the failure to achieve that political goal, the Trump administration and Congress have made additional changes, which have further destabilized the ACA. These maneuvers have had dramatic implications regarding shifting perspectives on who is to blame for the challenges of the ACA. A telling Kaiser Family Foundation Poll suggests that Americans now largely consider President Trump and the republicans to be responsible for the ACA moving forward.


In November, Republicans lost control of the House while slightly increasing their hold in the Senate. Emboldened by the debate regarding repeal and replace, the Democratic base is in many cases openly calling for an end to Obamacare and replacement with options such as single payer, Medicare Extra, Medicare for all and other government directed programs. These options are all forms of healthcare delivery that would likely have been unthinkable for a major political party to champion just a few years ago. The implications for the Democratic party supporting a shift to “single payer” in a system currently dominated by employer-based insurance is unclear. While dramatic changes are unlikely with the current divided government, we live in interesting times.

A link to the full article is provided:


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