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Eliminate, rename or replace the ACA?

December 27, 2016
by Ron Manderscheid, PhD, Executive Director, NACBHDD and NARMH
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Within a few short days after the celebration of the new year, we likely will be confronted with a major effort to “repeal” the Affordable Care Act (ACA). I put the word repeal in quotes, since it is entirely unclear what the word will mean in this context. Here, I would like to make a few general comments about the ACA, and then explore some potential meanings of the word “repeal” and their probable implications for our actions.

The ACA already has had a tremendous impact on health insurance coverage and healthcare delivery throughout the United States. More than 21 million people have become newly insured. This has reduced our national uninsurance rate to less than 10%, the lowest in our history. About 4 million young adults under age 26 now have health insurance coverage through their family’s policy. No person with a prior disease condition any longer can be denied health insurance coverage.

Person-centered, whole-health care championed by the ACA now is becoming the norm. This is being achieved through integrated care delivery that spans behavioral health and primary care, through the effective use of peers in all care settings, through much greater attention to disease prevention and health promotion, and through reform of financing to emphasize quality of care rather than quantity.

Thus, in many respects, it is quite comforting to observe that the ACA genie already is out the proverbial bottle, never to be contained again. Stated a different way, the ACA genie has become part of our healthcare culture, and culture cannot be contained by strategy alone.

Now to some of the likely meanings of “repeal”:

First, the most obvious definition of “repeal” is to eliminate the ACA through congressional and presidential action. I strongly believe that this option is quite simply a nonstarter. Only a buffoon actually would believe that insurance for 21 million persons could just be eliminated without dire and potentially fatal consequence to our healthcare system or even our overall economy. We must oppose this option from the outset.

A second definition of “repeal” is to rename the ACA. Under this option, the congress and president would make superficial changes in the ACA, repackage it slightly, and claim it as their own. They could then assert that they had successfully eliminated Obamacare. In my judgment, this option would be potentially acceptable. In business, it is termed shadowing. We could support this alternative, depending upon the specifics.

The third definition of “repeal” is to replace the ACA. This now frequently is called “repeal and replace”. The critical issue here is what would constitute replacement. One option would be to replace ACA health insurance and system reforms with inferior alternatives, or, in other words, “bait and switch.”  The other option would be replacement with equal or better alternatives. Clearly, we must oppose the former and support the latter.

As the meaning of “repeal” becomes clarified over the next one to three months, the strategy we must invoke also will become clear. In any event, the genie will be our ally for whichever strategy we choose.

Begin today to prepare for the coming debate on the ACA. It soon will be upon us. A good way to start is to ask yourself, “How have I and others in my community benefitted from the ACA?”



Ron Manderscheid

Exec. Dir., NACBHDD and NARMH

Ron Manderscheid


Ron Manderscheid, Ph.D., serves as the Executive Director of the National Association of County...

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