Erik McGregor/Sipa USA via AP
Any Obamacare repeal written by Republicans would be awful—despite Trump’s claim that he has “concepts of a plan.”
The biggest legislative failure of the Trump administration was his attempt to repeal Obamacare. After six years of Republicans voting over and over again to do it, only for the bills to be blocked in the Senate, they got their chance in 2017. The replacement “plan” would have made everything about health care worse, and was horrendously unpopular. When it failed by one vote in the Senate, I suspected—or hoped—the GOP would quietly ditch this effort.
Alas, that is not what happened. Speaker of the House Mike Johnson said recently that his party was still bent on throwing health care in America into turmoil. “No Obamacare,” he told reporters. “The ACA is so deeply ingrained, we need massive reform to make this work, and we’ve got a lot of ideas on how to do that.”
Given the GOP’s previous record, and the fact that the party is even crazier now than it was in 2017—the vote that saved Obamacare back in 2017 was cast by Sen. John McCain (R-AZ), who is now dead—I take Johnson at his word.
But that’s not all Trump would do. In addition to repealing Obamacare, he is certain to try to ban abortion nationally, either through Congress or through judicial rule-by-decree, which would not only wound and kill thousands of women whose pregnancies go wrong, but also devastate basic gynecological care across the country. He will also attack vaccine requirements in schools and put the most crackbrained anti-vaccine lunatics in the country in charge of the federal public-health bureaucracy. The vaccine wall protecting the American people from formerly eradicated viruses would erode, with measles, polio, whooping cough, mumps, rubella, and God knows what else making a comeback. Thousands of people, mostly children, would die in agony.
Kamala Harris, by contrast, wants to build on Obamacare by, among other things, extending insurance subsidies and price caps on prescription drugs, and adding a new home care benefit into Medicare. If she can, she will also sign a law legalizing abortion nationally. Just like with climate policy, the contrast couldn’t be starker.
Let me start with Obamacare. This law expanded insurance coverage through its exchanges and the expansion of Medicaid, and also set up a vast array of regulations and subsidies to shape insurance and provider systems into a somewhat more reasonable structure. These include a ban on lifetime coverage limits, guaranteed issue of insurance without exclusions for pre-existing conditions, actuarial value requirements so the insurance you receive is at least minimally useful, and so on.
Any Obamacare repeal written by Republicans would be awful. They have spent no time thinking of a better alternative—Trump said he had “concepts of a plan” during the debate—because there is no way to make the system better without spending more money, adding more regulations, or both. Outside of racism and cheating elections, the sine qua non of Republican domestic policy is cutting welfare programs, regulations, and taxes on the rich. None of that coheres with investing in health care access and making sure it’s good.
How bad Trump’s repeal would be depends on the details. The whole health care system has been reoriented around Obamacare’s structures, at great time and expense. Simply tearing them out root and branch would throw between 21 and 24 million people off their insurance, with about 14 million of them off Medicaid, according to the Commonwealth Fund. At the same time, a major source of revenue for providers would dry up. Hospitals would go belly-up by the thousands, particularly in rural and low-income areas where they are already struggling (thanks in part to oligopolist rollups) and Medicaid is the major insurer.
An abortion ban plus Obamacare repeal would wreak untold havoc on medical providers.
However, if Trump preserves the most popular marquee regulations of Obamacare, like the requirement that insurers have to offer policies to everyone and can’t discriminate against sick people, it would be even worse. Without the premium support and other subsidies that backstop those regulations, premiums in the non-group market would increase sharply, driving out the healthiest people and leading to a death spiral. Commonwealth estimates that 30 to 32 million would lose their coverage under this scenario. I suspect this is the most likely future if Trump wins.
Second, abortion. This has been portrayed in politics and the media as something that happens solely when a pregnancy is unwanted. While that does account for most of them, America has since learned at a painful and bloody cost that abortion is also a fundamental component of maternal care. Pregnancy is difficult, dangerous, and commonly goes wrong. Thousands of women every year with wanted pregnancies end up needing an abortion to protect their health. Since Dobbs, many such women in red states have indeed become gravely ill or died because they could not get an abortion in time.
As a result, gynecologists and obstetricians are fleeing red states en masse, because Republicans have made it illegal to do their jobs ethically. Red states with strict abortion bans have not only gravely violated the rights of their female populations, they have also devastated their gynecological services, particularly in rural regions. Huge stretches of states like Idaho now have no gynecologists at all. Women needing routine care—like older women with common menopause complications—now have to drive for hours, or go without.
Trump has been mealymouthed about abortion, but he quite obviously would sign a national abortion ban. He refused to say if he would at the debate, but he did not say he’d veto it either, and he has always done the bidding of his evangelical base. It was Trump judges on the Supreme Court, after all, who overturned Roe v. Wade.
An abortion ban plus Obamacare repeal would wreak untold havoc on medical providers. In addition to losing a massive source of income as the uninsured rate roughly doubles, they would lose thousands of critical staff. Many ob/gyns would flee abroad to the many countries with doctor shortages like the U.K. or Germany—and they might be joined by colleagues in other departments. A recent survey of physicians and med students found that 76 percent would not even apply to work in a state with an abortion ban, probably because they know how critical abortion care can be, or want to start a family themselves.
Finally, there is public health. Robert Kennedy Jr., one of the most influential anti-vaccine cranks in the world, who was directly responsible for a measles outbreak in Samoa that killed 83 people, has said that Trump promised to put him in charge of public health. “I’m going to let him go wild on health. I’m going to let him go wild on the food. I’m going to let him go wild on medicines,” Trump said recently. Howard Lutnick, the head of Trump’s transition team, said on CNN this week that he bought RFK’s dog-brained anti-vaccine misinformation, and that he wants to make changes that would lead to vaccines being taken “off the market.” Trump himself has promised to pull funding from any public school that requires vaccination—the major mechanism by which herd immunity is maintained.
Before vaccines, measles, mumps, rubella, and polio infected millions of Americans every year. In 1952, more than 3,000 children died of polio, and thousands more were permanently paralyzed. Measles typically killed 400 to 500 people a year, again mostly children. Mumps is usually mild, but can cause viral meningitis, which can be fatal. And ironically given the anti-vaccine lie that vaccines cause autism, the rubella vaccine actually prevents autism, because if pregnant women get it, the virus is notorious for causing severe birth defects, including but not limited to autism.
What’s more, untold hundreds of thousands of Americans were left with long-term complications from these viral infections—as we’re now learning, COVID-19 is not at all unique in how an infection sometimes leads to lingering aftereffects.
Kamala Harris’s health care plans are a lot easier to describe. Most importantly, she would not repeal Obamacare, or sign a national abortion ban, or put deranged nutcases in charge of public health.
However, she does have a positive agenda as well. Most importantly, she has said repeatedly that she would legalize abortion nationally, and she would certainly nominate Supreme Court justices who share that view. She intends to renew expanded Obamacare subsidies that are scheduled to expire in 2025, preserving the insurance status of millions. She proposes to expand the Biden administration’s price caps on prescription drugs to more treatments. The $35 cap on insulin would be expanded to all Americans, not just Medicare enrollees. She would add an at-home care benefit to Medicare—potentially a major reform that could save tens of millions of families a ton of money. And she would continue the price negotiation of more drugs through Medicare.
The choice is clear. Harris is not a revolutionary, but she would build on the health care status quo, adding some new elements and patching some of the biggest holes in the system. If Trump wins, and he and RFK Jr. get your kid infected with polio, chances are good that if you seek care at the local hospital, it will be bankrupt.
