New York, United States – After less than a month of President Donald Trump and his team of business-friendly nationalists occupying the West Wing, his predecessor, Barack Obama, already seems like a dot fast disappearing on the horizon.
Trump and his fellow Republicans have long vowed to rip up Obama’s legacy. Headlining their agenda is the low-cost healthcare policy that bears his name – Obamacare – which looks bound for the dustbin of history.
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To many in the rich world, delivering reasonably priced healthcare for all is viewed as a job for government. But the US plays by its own rules. Americans are typically insured by employers or expect to pay doctor’s bills from their own pocket.
When it was passed in 2010, Obamacare, or the Affordable Care Act (ACA) as it is formally known, was designed to provide reasonably priced health insurance to the estimated 15 percent of Americans who were not covered.
It did this by offering discounts on government-backed health insurance plans that are sold through exchanges – with websites akin to online shopping and travel sites – where buyers can compare prices for coverage.
The law also stopped insurance firms from denying coverage to people with pre-existing health problems, let individuals stay on their parents’ plans until the age of 26, and enlarged the government-run Medicaid scheme for the poor.
By obliging all Americans to get coverage, the ACA sought to get more young, healthy people to buy into policies and spread the cost of the medical bills being racked up by millions of older and sicklier folks.
Conservatives rejected Obamacare from day one. They called it a poorly executed “job killer” that impinged on private businesses and individuals and sent insurance bills up. Only hours after being sworn in on January 20, Trump fired the starter pistol on ending it. That won’t be easy. Some 30 million people may lose coverage when the ACA goes. Cutting benefits is harder for politicians than introducing new ones. Republicans talk of “repeal and replace”, but have yet to agree on the replacement.
Divisions in Washington reflect those nationwide. A Pew Research Center survey from December found that 48 percent of respondents disapproved of the signature policy of Obama, a Democrat, while 47 percent approved.
To help understand Washington’s political dilemma, Al Jazeera spoke with two Americans – an older woman who beat back cancer, and a younger man who suffers from asthma – about how they felt about Obamacare:
Donna Smith, 62, and her husband, Larry, 72, live in Denver, Colorado, a “blue” Democratic state
They had insurance at the time, but out-of-pocket expenses left them penniless. Filmmaker Michael Moore featured them in his expose, Sicko. The couple was forced to move into Donna’s daughter’s basement in 2006 when medical bills piled up to cover treatment for her uterine cancer and his heart disease.
“It’s terrifying to be in that position. You feel guilty for needing care, and wedded to a job and its health insurance policy when you may want to move on,” Smith said. “The stress from medical bills while you are trying to recover doubtless makes things worse.”
Now, Larry has passed 65 and qualifies for Medicare. Donna pays the “outrageous expense” of $875 a month for an ACA insurance policy that pays for the oxygen machine she needs for her breathing problem, among other health woes.
“Without Obamacare, there wouldn’t be an insurance company in this country that would cover a 62-year-old, three-time cancer survivor with ongoing respiratory problems like me,” Smith told Al Jazeera.
She has to buy insurance for three more years before her state-funded Medicare kicks in. She does not want to be a burden on her children, and fears Republicans axing the ACA without a replacement for people such as her.
“If Republicans take away what Obamacare provides, I won’t be able to afford my oxygen equipment out-of-pocket and will struggle to breathe. For me, it’s more than a policy discussion. The message I’m getting is that my life doesn’t really matter,” she said.
“Trump talks a lot about being popular. But that’s not very populist.”
Alex Popovici, 31, a freight broker from Philadelphia, Pennsylvania, a “red” Republican state
When he was jobless for three months in 2016, Popovici studied the Obamacare options available and found them wanting. At $300 a month, they were costly and would not fully cover his $250-per-month asthma medicines.
“I needed Obamacare, and it didn’t do anything for me, so I opted not to get it,” Popovici told Al Jazeera.
He’s back in work now; his company co-pays his insurance. The introduction of Obamacare has raised the cost of his annual contributions by about $150 a year, but, he says, the burden on his employer is greater – leading to fewer pay rises and smaller bonuses.
He supports the idea of richer, healthier people helping the poor and frail, but does not want to shoulder too much of the burden. “Obamacare works really well for low-income people and the poor, but for the middle class, it just doesn’t work,” he said.
“If Republicans came up with something that resembles comprehensive, universal healthcare, with acceptable costs, I’d be more than happy,” he said. “You shouldn’t repeal without having something to put into place.
“They’re taking an irresponsible approach to a serious problem that Obama was never able to figure out.”
No alternative coverage
It almost looks impossible for Republicans to come up with an alternative system that will please everybody. It seems that, at the very least, key parts of Obamacare will be cut, while others may remain.
Even Obamacare fans see its flaws. Healthcare premiums keep rising, and insurance firms are pulling out of the exchanges. Critics talk of a “death spiral” in which rising premiums deter buyers, shrinking the pool and inflating costs once again.
Tom Price, Trump’s new head of the Department of Health and Human Services, suggests replacing the ACA with tax-credit subsidies to help buyers. Under his plan, insurers could sell across state lines and create special, subsidised pools for “high-risk” folks.
Liberals say that Obamacare never went far enough, and look to the healthcare systems of Western Europe and parts of Asia, where people enjoy tax-funded universal healthcare or get their upfront payments reimbursed by the government.
On Tuesday, former Democratic presidential wannabe Bernie Sanders made his case for a “single-payer” system in the US, in which the government would collect taxes to provide universal healthcare at privately run hospitals and clinics.
He went head-to-head in a televised CNN debate with Ted Cruz, who similarly sought the Republican nomination in the 2016 election. The Texas senator argued that Obamacare cost jobs and that universal healthcare would hurt the economy.
While there is little about healthcare on which all Americans agree, there is one area of cross-party accord. Some 69 percent of Republicans and 63 percent of Democrats say that healthcare costs are too high and should come down.
The US lavishes 17.1 percent of its economy on healthcare, more than any other country, with inauspicious results. While Obamacare spread out the costs of healthcare, it failed to tackle the eye-watering prices set by providers and insurers, critics say.
Even Trump has spoken out against the “astronomical” costs charged by drug-makers. However, the powerful US medical lobby has a solid track record in persuading congressmen not to trim its profits.
There are doubtless many rows on healthcare to be had in Congress in 2017. Whatever policy emerges from the rancour, it will struggle to get a clean bill of health from politicians on both sides of the aisle.
Follow James Reinl on Twitter: @jamesreinl