Paul Ryan wants you to know that everything is going to be okay. Once he and the rest of the congressional Republicans repeal the Affordable Care Act, a.k.a ObamaCare, he says, ‘We will give everyone access to affordable health-care coverage.’ And he’ll make sure that ‘no one is left out in the cold’ and ‘no one is worse off.’

If you’re not sufficiently comforted, Trump whisperer Kellyanne Conway is here to assure you that ‘we don’t want anyone who currently has insurance to not have insurance.’ So there’s really nothing to worry about.

But let’s wave away that fog of friendly rhetoric and get down to what will actually happen once Republicans are done with the ACA. The only thing they can agree on at the moment is that they want to repeal it, thrust a dagger in its black heart, shoot it and drown it and burn it, strap it to a rocket and fire it into the sun. Once they’re done doing that, they’ll set a date in the future for repeal to actually take effect — perhaps after the 2018 midterm elections, so they don’t have to worry too much about a backlash — then figure out what to replace it with.


This strategy is known as ‘repeal and delay.’ The theory is that once repeal is taken care of, the threat of a looming health-care catastrophe will concentrate everyone’s mind (maybe even Democrats!) and a replacement plan will come together. And it will be, as Donald Trump promised on the campaign trail, ‘something terrific.’

The trouble with reform, though, is that it always has winners and losers. So let’s take a look at who the losers in the ACA’s repeal are going to be. Wherever possible, I’ll look both at repeal itself and at whatever we can tell about what a Republican replacement plan might be.


12 million people on Medicaid. That’s the number who are newly insured thanks to the ACA’s expansion of Medicaid. Repeal the ACA, and they lose their coverage. After Republicans do that, they are hoping to turn Medicaid into a block grant, which by eliminating federal rules on who must be covered will give states more latitude to toss even more people off.

9 million people on the exchanges. That’s the number who get substantial subsidies to buy coverage, and who wouldn’t be able to afford it otherwise. The Republican answer for them is to make available bare-bones catastrophic plans, which don’t cover any routine medical needs but will help if an expensive illness or accident befalls them.

1.4 million young people. That’s the number of those between the ages of 19 and 25 who are allowed to stay on their parents’ insurance thanks to the ACA. The Republicans insist that this is one of the parts of the ACA they want to keep.


52 million people with pre-existing conditions. That’s the Kaiser Family Foundation’s estimate of how many Americans have conditions that threaten their ability to get coverage, and whom insurers are now required to cover. If you’ve bought insurance since the ACA went into effect, you were probably relieved to find that you didn’t have to document every time you’ve been to the doctor in the last decade the way you used to, with the threat that if there was something the insurance company didn’t like the look of, they’d deny you. Well, get ready to go through that fun process again!

Republicans say they want to protect all those people, but they can only do it in a tortured fashion, by requiring insurers to cover you if you maintain ‘continuous coverage,’ and if you don’t — say, because you lost your job or started your own business — then you’d be shunted into a ‘high-risk pool,’ which is the worst way to cover people with pre-existing conditions and is almost guaranteed to be underfunded and outrageously expensive.

Seniors who take expensive medication. Remember the ‘donut hole’? When a prescription drug benefit was added to Medicare in 2006, it included a donut hole, where your drug benefits disappeared after a few thousand dollars, then started up again after you spent a healthy chunk of your own money. It meant sometimes crippling drug costs for seniors on fixed incomes, which is why the ACA phased it out. Repeal the law, and the donut hole comes back.


Hospitals. Before the ACA, hospitals had to spend billions of dollars treating people who had no insurance and showed up to emergency rooms; some of those costs would be borne by the states. Because so many people would now have insurance, particularly poor people who could get Medicaid, the hospital industry was willing to accept some cuts to their reimbursements, which helped make the whole thing more affordable. Last month, the American Hospital Association warned that if the ACA is repealed, the nation’s hospitals will lose hundreds of billions of dollars. ‘Losses of this magnitude cannot be sustained and will adversely impact patients’ access to care, decimate hospitals’ and health systems’ ability to provide services, weaken local economies that hospitals help sustain and grow, and result in massive job losses,’ the group’s president said.


That doesn’t even cover everyone who’ll be victimized. But one of the most important things to understand is that as Republicans repeal the ACA and come up with their own version of the American health care system, the fundamental goals that Democrats pursued, like universal coverage and health security, will no longer be operative. Those just aren’t things Republicans particularly care about. They’re much more concerned with making sure the system has as little government involvement as possible, whatever the human and financial cost.


Which is why they’re now trying a new spin, saying that their goal is not universal coverage but ‘universal access.’ In practice, that means all Americans will have ‘access’ to coverage in the same way that we all have ‘access’ to BMWs.

We don’t yet know for sure what the Republican ‘replacement’ for the ACA is going to be, because they don’t know themselves. What we do know is that when you repeal the law, a lot of people are going to lose a great deal — in money, in security, and even in their lives. It’s something we shouldn’t forget when Republicans assure us of of how terrific everything’s going to be once they’re done.