Peter Boland

The subtitle of this book is “Why you should care,” and the authors present a compelling case why everyone should and why the current national policy debate goes far beyond the pros and cons of the ACA and its proposed replacement, the American Health Care Act (AHCA). The debate is fundamentally about the role and reach of government. The book challenges the policy assumptions of both Democrats and Republicans. It explains how our country is so ideologically polarized that a consensus on health care is unlikely to emerge for the foreseeable future.

One of the most intriguing insights of the book is how often Republican leaders advanced progressive health care programs in the past but, in the last decade, how little they have contributed to pragmatic health care legislation because of a change in political ideology.

From Obamacare To Trumpcare book cover

From Obamacare To Trumpcare
Harry Nelson and Rob Fuller

The authors, Harry Nelson and Rob Fuller, are well-respected health care attorneys in Los Angeles. They trace the contours of the current debate back to the controversy over the passage of Medicare and Medicaid in 1965. Many of the lessons learned from legislative battles fought more than 50 years ago are contrasted with Clinton-era failures and then how the Obama administration learned from them, fashioning a strategy that quelled the potential opposition of health care providers and pharmaceutical companies. Concessions were made to providers and payers. One result was that the provisions of the ACA that might have tackled costs were blunted.

The ACA’s bumpy road to implementation reflects the deep-seated political and philosophical divide between the two parties about the role of government and pros and cons of market-driven solutions. Some Republicans want the AHCA to go much further—it is disparaged as Obamacare Lite in some circles. But relative to the ACA, there’s no doubt that the AHCA reflects the prevailing Republican belief in a much narrower role for government. The new law will place far more financial responsibility for health care on individuals and give states more discretion over their Medicaid programs.

The AHCA will remove current subsidies for individuals who buy coverage through the exchanges and replace them with tax credits that, starting next year, can be used to purchase coverage either through an exchange or outside one. The ACA subsidies are indexed to income and premium; the AHCA’s are indexed only to age and in amounts that, along with other changes, favor the young and disadvantage the old.

AHCA also loosens the rules on the types of health plans that can be sold in the nongroup market and will nearly double the allowable contribution to health savings accounts. The approach the House Republicans have taken to tax credits for health insurance is in keeping with the party’s current philosophy of using tax policy as a vehicle for redefining a smaller, less obtrusive role of government.

But ideologically pure the AHCA is not. In fact, it keeps many of the most popular provisions of the ACA: the ban on pre-existing conditions exclusions and premium differences, allowing adult children to stay on their parents’ policy till they are 26, caps on out-of-pocket expenses, and no annual or lifetime limits.

Nelson and Fuller anticipated many aspects of the AHCA and the negative consequences that the ACA’s repeal will have for low-income and elderly Americans. They see the legislation—correctly—as a pivot away from prior Republican administrations that expanded coverage for seniors.

From Obamacare To Trumpcare uses common sense to analyze health care. And even knowledgeable readers will appreciate the authors’ efforts to demystify the jargon that often obfuscates the underlying political agenda of both parties. Nelson and Fuller skillfully present a balanced perspective, so readers will leave their book with something that’s in scarce supply—understanding and context.

Peter Boland of Boland Healthcare is a health care management consultant in Berkeley, Calif., and a member of Managed Care's editorial advisory board.