How Obamacare Survived Trump and What Biden Is Doing: QuickTake


June 17, 2021 10:17 am

The U.S. health-care law known as Obamacare spent its first decade dodging a series of existential risks. By a single vote in the Senate, the law survived a repeal attempt in 2017 pushed by then-President Donald Trump. The Supreme Court shut down the latest challenge in a 7-2 decision that denied Republican states’ challenge to the law’s constitutionality. Joe Biden’s presidency could give Obamacare (more formally, the Affordable Care Act) a chance to grow beyond its initial scope. Biden pushed for the law as vice president under President Barack Obama.

1. How much of Obamacare survived under Trump?

Most of it, including tax subsidies to help people afford coverage and, in 39 states (including the District of Columbia), expanded eligibility for Medicaid, the U.S. health insurance program for low-income Americans. Key Obamacare consumer protections that also remain in place allow children to stay on a parent’s policy until age 26, require insurance companies to treat people with preexisting conditions equally and prohibit the imposition of annual or lifetime coverage limits.

2. How many Americans are covered because of Obamacare?

Roughly 20 million. About half joined Medicaid as a result of the expanded eligibility. The rest found coverage by comparison-shopping among private insurers at government-run online marketplaces, where subsidies help people afford coverage. (The expanded version of Medicaid enrolls most adults earning up to 138% of the poverty line.) Even with Obamacare in place, 28.9 million Americans lacked coverage in 2019, two million more than in 2016, according to the Kaiser Family Foundation. The U.S. is an outlier among developed countries by not having universal health coverage.

3. Which parts have been eliminated?

Obamacare originally required all states to participate in the expanded Medicaid program; the Supreme Court, in a 2012 split ruling that upheld most of the law, struck down the requirement. The law as written also required all Americans to buy health insurance — the so-called individual mandate — at risk of a tax penalty. The Trump administration whittled away at Obamacare with executive actions, including one that cut funding for so-called navigator programs that help sign people up. A tax overhaul passed by Republicans and signed by Trump in 2017 eliminated the penalty for noncompliance, rendering the mandate moot. That paved the way for the broader constitutional challenge to the law that the Supreme Court rejected in June.

4. What did Biden promise to do about Obamacare?

He campaigned on a pledge to expand the program by offering a government-provided alternative to private insurance that’s known as a public option, a proposal he’s called “Bidencare.” It would be available to all Americans, including those who get their insurance through work. Low-income Americans would be automatically enrolled and, if eligible, their premiums would be free. Though he hasn’t released further details since taking office, his plan set him apart from the progressive wing of the Democratic party, which has pushed the idea of achieving universal coverage by scrapping private insurance and replacing it with “Medicare for All.”

5. What’s he done?

He reopened the federal market from Feb. 15 to Aug. 15, allowing more people who are uninsured during the pandemic to sign up for health coverage. Biden’s fellow Democrats in Congress passed a $1.9 trillion Covid-19 relief package that increased Obamacare subsidies for two years and offered more money to the 12 states that haven’t expanded Medicaid if they start covering the law’s newly eligible adult population. Democrats may look to make some of those changes permanent.

6. Is Obamacare viable for the long term in its current state?

Some economists worry about a “death spiral” of rising costs in the absence of a mechanism, like the individual mandate, that forces healthy Americans to get covered, since healthier people buying coverage keeps costs down for sick people. That’s one issue. Another is the limited coverage options available to Americans in rural and remote parts of the country. And in the mostly Republican-led states where elected leaders have declined to expand Medicaid eligibility, many residents fall in a coverage gap, earning just enough income that they don’t qualify for subsidies.

7. Do Americans want Obamacare to stay or go?

U.S. public opinion of the law was mostly negative from its passage in March 2010 until Trump became president and sought to repeal it, according to tracking surveys by the Kaiser Family Foundation. The threat of elimination — which failed when the late Senator John McCain of Arizona gave a memorable thumbs down in an early morning vote in 2017 — put a spotlight on popular provisions of the law, notably its prohibition on insurers charging sick people more for coverage and its list of “essential health benefits,” like hospitalization and maternity care, that must be covered. Kaiser’s tracking survey found in May that 53% of Americans viewed the law favorably, while 35% viewed it unfavorably.