What Would Republicans Do Instead of the Affordable Care Act?

(This article was published on Friday, September 18 on the Health Affairs Blog.  It was prepared by me and Max Fletcher, a Master of Public Health student at the Harvard TH Chan School of Public Health.)

A new spate of proposals from Republican presidential candidates to repeal and/or replace the Affordable Care Act (ACA) raises the important question: Given an unobstructed opportunity, what would Republicans really do with the Affordable Care Act? Would they repeal the law wholly or just in part? With what might they replace it?

Some suggest that Republican Congressional leaders only advance full repeal to placate their Party’s conservative base, knowing well that repeal cannot survive a certain veto while Barack Obama is President. In January 2017, that obstacle will vanish if Republicans control the White House and both branches of the U.S. Congress. What then?

Unfortunately, the proposals now being advanced by the Presidential candidates are far less than comprehensive, and leave many more issues unanswered than answered.

Though no ACA replacement plan has progressed in either branch (or in any standing committee) of Congress since the law’s 2010 signing, Republican office holders and conservative think tanks have advanced expansive proposals. We identified eight plans offered between 2012 and 2015 that address the ACA’s fate and propose substantive replacement. We examined each in detail to determine the extent of agreement on alternatives to the ACA. We created a chart comparing the eight proposals according to key policies. Table 1 below provides identifying information about the eight plans:


Of the eight proposals, four were advanced by Republican Members of Congress. The most prominent of these is the Patient CARE Act offered by Sens. Richard Burr (R-NC) and Orrin Hatch (R-UT) and Rep. Fred Upton (R-MI); the latter two are the current chairmen of the Senate Finance Committee and the House Committee on Energy and Commerce respectively, both committees with primary ACA jurisdiction. Though narrative versions of Burr-Hatch-Upton were released in 2014 and 2015, the authors have not translated their proposal into legislative language that can be evaluated by the Congressional Budget Office (CBO). While the other Congressional proposals have been introduced as legislation, none have received CBO scores. Continue reading “What Would Republicans Do Instead of the Affordable Care Act?”

The Curious Politics of the “Cadillac Tax”

A provision of the Affordable Care Act popularly – or unpopularly – known as the “Cadillac Tax” is getting lots of attention now, even though it doesn’t take effect until 2018. Voices from both parties want quick repeal. And the politics are strange.

Briefly, the tax is a 40% excise on high cost health insurance policies that cost more than $10,200 for individuals and $27,500 for families in 2018. It’s 40% on the increment, so an individual policy costing $11,200 would cost an extra $400. It was included to help finance cadillacthe ACA’s cost and to apply pressure where it hurts the most to restrain the cost of health insurance.

When the ACA was signed into law in 2010, many critics asked: “where’s the cost containment?” One answer was: “the Cadillac tax.” The frequent response was derisive laughter: “The tax doesn’t hit until 2018 and it will be repealed well before then.” No laughter now. Continue reading “The Curious Politics of the “Cadillac Tax””