Sign at a protest against the repeal and replacement of the Affordable Care Act (Photo: Getty Images)
Sign at a protest against the repeal and replacement of the Affordable Care Act (Photo: Getty Images)


Explainer: how does healthcare in the US really work?

And what’s at stake when Donald Trump and Republicans try to dismantle Obamacare? Jean Hannah Edelstein rounds up the facts

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By Jean Hannah Edelstein on

If you’ve been watching the US healthcare news and thinking ‘huh?’, you’re not alone. When I moved back to the States in 2014, after nearly ten years of using the NHS, I behaved like a bumbling idiot every time I went to the doctor. And then I was diagnosed with Lynch Syndrome: a hereditary cancer gene that means that I have to see half a dozen specialists annually, in addition to having frequent (expensive) scans.

Like many Americans, I don’t completely understand our healthcare system, but for you, readers of The Pool, I will do my best.

What was healthcare like in the US before Obamacare?

Before Obamacare, your best bet for getting health insurance was through full-time employment. If you worked for a big company, your healthcare was covered as part of your benefits package.

It’s in the best interest of many companies to offer healthcare to their employees so that they don’t, you know, get too ill to come to work. But before Obamacare, companies were not obligated to provide health insurance to their employees. That meant you could work full-time and still have to pay for your own health insurance.

Even if you had health insurance, that didn’t mean that your healthcare was free at the point of delivery. You had to pay a monthly fee, called a premium, in addition to a further payment — known as a copay — when you saw a healthcare provider.

You also had to meet an annual deductible. For example: if your deductible is $5000 annually, and you go to see your GP twice during the year, your insurance doesn’t pay for it unless the cost of your GP visits is more than $5000. Even though you’re paying your monthly premium.

Pre- and post-Obamacare, even with insurance, this means that healthcare is an important consideration in a family budget. My family was lucky enough to have insurance through my dad’s job when I was growing up, but my frequent episodes of childhood asthma still cost my parents hundreds of dollars. An emergency appendectomy performed when I was visiting my grandparents in Chicago was a huge problem because I was insured in New York, not in Illinois.

If you were buying insurance without it being subsidised by an employer before Obamacare, that was crazy expensive, so many people just didn’t. Insurance premiums were calculated based on your health, and if you had a so-called pre-existing condition, your monthly payments to be insured were higher (much higher). Pre-existing conditions covered pretty much any kind of ailment — cancer, yes, but also depression and pregnancy. In some cases, being a woman, or being a victim of rape or domestic violence counted as pre-existing conditions, too.  Doctors sometimes advised people not to get tested for genetic diseases like Lynch Syndrome for fear that positives might make them uninsurable. For folks without health insurance, primary care was something to be avoided, going bankrupt because of a long illness or injury was a real possibility, and in some cases, if you couldn’t pay for treatment, then you’d just...die.

What happened after Obamacare?

With the passage of the Affordable Care Act in 2010 (that’s the official name of Obamacare), all kinds of things changed, but here are the ones that mean the most to your average American:

Everyone had to be insured. There were lots of different ways to get insurance — which I’ll describe in a moment — but the bottom line was that it was no longer an option to not have insurance without a penalty.

Businesses had to provide affordable insurance. Any company with over 50 employees had to provide an affordable insurance option to anyone working more than 30 hours a week, aged 26 or over. (People under 26 were now able to be claimed as dependents on their parents’ health insurance plans.)

Government-run insurance exchanges were established. In each state, these exchanges provided options for state-regulated insurance plans that could be purchased by businesses and small individuals. Depending on where you live, if you’re within a certain income bracket, you may be eligible for government subsidies to help to meet the cost of paying for that insurance in the marketplace.

After Obamacare, it was no longer legal for insurers to charge people more money because they reckoned they had a higher chance of getting sick because of their gender or health history

Pre-existing conditions and gender were no longer grounds for discrimination. After Obamacare, it was no longer legal for insurers to charge people more money because they reckoned they had a higher chance of getting sick because of their gender or health history. This was huge for millions of folks, especially people with disabilities and chronic illnesses, who were now able to get insurance for the first time.

Medicaid was expanded. Medicaid is government-provided healthcare in the US, which was allocated to people with low incomes. Obamacare increased the number of people who were eligible for Medicaid, based on income.

Obamacare wasn’t perfect

Obamacare has been a lifesaver (literally) for many Americans but for some people, it’s still prohibitively expensive. Folks who make too much money for Medicaid or insurance purchase subsidies may still need to pay hundred or even thousands of dollars a month to insure themselves and their families. The exchanges didn’t bring prices as low as legislators hoped.

This means that some people still make the decision not to have insurance, because paying the penalty — at least $95, at most 1 per cent of your income — is cheaper. I chose that option for six months last year while I was freelancing, to save money. I was very lucky to be healthy that whole time.

Obamacare hasn’t gotten rid of the deductibles and copays, either: depending on your health insurance plan, you may still need to pay hundreds or thousands of dollars before your insurance will cover your treatment. Not all doctors accept all insurance plans: on one occasion, despite being insured, a last-minute change of staff meant that a hospital billed me $7000 for a small surgical procedure, because the second-choice anaesthetist did not accept my plan. When I objected, the hospital billing department said that I should have told them at the time of the procedure. “I was literally asleep,” I said.

Why don’t Republicans like Obamacare?

Trump’s statement that “nobody knew that health care could be so complicated” demonstrated that he knew nothing about the true costs of health care. Why would he? He’s very rich. But he’s also very racist — as demonstrated by his years-long efforts to prove that Obama was not born in the US, despite the fact that Obama was born in the US. Trump is determined to reverse Obamacare because he wants to undo Obama’s signature legislation, and not because he really cares about healthcare.

As for Republicans in general: they’re keen on individual rights. So they believe that a national mandate that everyone should have health insurance somehow impinges on people’s individual rights to, I don’t know, die unnecessarily from treatable diseases because they can’t raise enough money from internet strangers to pay for surgery.

Republicans are also very keen on helping the rich get richer, and they want to get rid of Obamacare so that they can provide wealthy folks with tax cuts, under the guise of encouraging “personal responsibility”.

But despite promising to “repeal and replace” Obamacare, the Republican Congress has failed to come up with a viable alternative. Last week, the “skinny” bill attempted to repeal Obamacare without offering a replacement. Experts — doctors, insurers and so forth — said that it would drive up the cost of healthcare and leave millions of people uninsured, but that didn’t stop the GOP. The bill also included plans to defund Planned Parenthood — one of the country’s  important providers of low-cost healthcare to women (and men, in fact). Fortunately, three Republican senators went against their party last week to reject the bill, keeping Obamacare in place. For now.

What’s next?

Healthcare reform is a personal issue for all Americans. I’m lucky: I live in New York, where the state government has committed to maintain a more equitable healthcare system regardless of what happens at a federal level. There’s real momentum in the campaign for single-payer healthcare. That said, I’m very aware that until that happens I need to stay in a job that provides me with decent insurance: my potential health needs are too high for me to risk having inadequate insurance again. It’s possible that a combination of illness and Trumpcare could lead to a scenario where I can no longer get health insurance. I am fortunate that am UK citizen and can return.

But of course that’s not an option for most Americans. Our Declaration of Independence asserts that life, liberty and the pursuit of happiness are key human rights. I feel like “going to the doctor” should fit in there somewhere. But there’s a long fight ahead to make it so.


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Sign at a protest against the repeal and replacement of the Affordable Care Act (Photo: Getty Images)
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