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ELECTION
IMPACT
THE FEDERALIZATION
OF HEALTH INSURANCE:
ACA Repeal and Replace Implications
An Opinion-Editorial By Alan Preston, MHA, Sc.D.
One of the campaign promises of the Donald Trump adminis-
tration is to repeal and replace the Affordable Care Act (ACA).
The nation is largely divided on this issue of repeal and replace.
And as one would imagine, the split is along party lines. The
2,400-page legislation is a rather complicated piece of legislation.
As in most legislation, the ACA has parts of it that are helpful and
parts that are hurtful. And some of the good or bad of the law de-
pends whether you benefit or not from the law. Beauty is in the
eye of the beholder in this case.
When I evaluate the effectiveness of legislation, I first look to
see if it will accomplish its objective. Whether I like the objective
or not is a separate issue. The name of the legislation is telling and
provides a clue to the objective. The Patient Protection and Af-
fordable Care Act.
Patient Protection; who are we protecting the patient from? Ac-
cording to the authors of the legislation, the patients were intended
to be protected from the big bad insurance companies. What is it
that the big bad insurance companies did that required 2,400
pages of patient protection legislation? There are two major com-
plaints by the authors of the legislation:
1. The insurance companies imposed an underwriting technique
on individual policies (not group policies sold to employers)
called pre-existing condition limitations. The ACA removed
20 San Antonio Medicine • January 2017
this underwriting practice which increased the price of insur-
ance for everyone. Under the old law, if someone was going to
purchase individual medical insurance to protect them from a
future financial loss, that person would not be covered for cer-
tain previously existing medical issues. Contrarily, if you pur-
chase car insurance, they always impose pre-existing conditions.
You can’t get in a wreck prior to purchasing insurance and then
ask the automobile insurance company to pay you for an acci-
dent that you were in before the insurance went into effect.
Otherwise, everyone would wait to purchase car insurance until
they had already been in an accident and not before. It should
be obvious to everyone why eliminating pre-existing condition
limitations (as happened under the ACA) would not work on
individual coverage; unless one wants to pay extremely high
rates. Which is where we are now!
2. Per the democrats that designed the ACA, they felt the insurance
companies charged too much money for too little coverage and
made too much profit in the process. Their solution in the ACA
was to mandate a robust insurance plan (the four-minimal es-
sential coverage metal plans) that covered nearly everything. This
forced the people in the marketplace to abandon the purchase of
what was characterized as low-end insurance policies. And the
democrats limited the amount of money an insurance company