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Obamacare v the revised Republican healthcare bill: the key differences

House Republicans voted on Thursday to repeal and replace Barack Obama’s Affordable Care Act. Here is what sets them apart

By Joanna Walters in New York / For the Guardian / Thursday 4 May 2017 11.25 EDT


Number of people left uninsured

The Affordable Care Act (ACA), also known as Obamacare: The nonpartisan Congressional Budget Office (CBO) predicted that if the ACA continued, the number of uninsured Americans – currently 28 million – would remain stable for the next decade.

The revised Republican healthcare bill: The CBO has not had time to estimate the impact of the revised GOP bill, so the House will have to vote on Thursday on the basis of the previous analysis of the version of the bill that in March failed to get enough support to come to a vote in the House. The CBO predicted that that bill would lead to nearly double the number of uninsured – 52 million – by 2026.

Individual mandate

ACA: Requires people who can afford health insurance to get coverage by acquiring a health policy if one is not already supplied via their employer. Failure to do so brings a penalty.

GOP bill: Would repeal the mandate and penalty, but if an individual is uninsured for more than two months, they will have to pay a 30% surcharge on their premiums when they seek coverage again.

Employer mandate

The revised GOP bill would scrap the mandate introduced under the ACA that obliges larger companies to provide affordable insurance to their workforces.


ACA: Imposes higher taxes on those with incomes above $250,000, on insurance companies and on the makers of medical devices, to help pay for the new system. It gives some tax credits to middle-income earners to assist with out-of-pocket health expenses such as deductibles and copays.

GOP bill: Would dismantle the bulk of the extra taxes that the ACA imposed and would repeal the above tax credits in 2020.

Expansion of Medicaid, the social healthcare program for low-income Americans

ACA: A total of 32 states – including New York, Ohio, Kentucky, Indiana, Iowa, Arizona and California – provided extra public money under the federal Medicaid program for health insurance and expanded eligibility, allowing millions more to afford coverage. Major states that did not expand Medicaid include Texas, Florida, Missouri, Virginia, Tennessee and the Carolinas.

GOP bill: Would allow the status quo to prevail temporarily, with the extra federal money for the Medicaid expansion continuing – but only until 2020. It’s unclear what would happen after that. States that did not expand Medicaid under the ACA would not be able to change their minds. Under the new legislation, states would also be able to impose certain new conditions and limits on those receiving Medicaid, such as the requirement to get a job.

Preexisting conditions

ACA: A major breakthrough under the ACA was the new obligation of insurance companies to offer coverage regardless of someone’s health record. They could no longer turn a person away for what was often a very loose interpretation of a “preexisting condition” and couldn’t jack up prices because of someone’s history. However, extra federal funding to subsidize the higher costs of this coverage was quickly swallowed up.

GOP bill: One of the big disputes among many Republicans over the revised bill (the Democrats are universally opposed) involved not just the amount of funding available to subsidize the extra cost of covering people with preexisting conditions, but the proposal that the ACA rules be changed so that insurers had to cover high-risk people – while in effect charging whatever they wanted. The bill going to a vote on Thursday still allows states to waive the rules that currently stop insurers from charging new customers more because of their health records. But states must also help the highest-risk people (often where cancer and heart disease are involved) get coverage. And a pivotal amendment introduced on Wednesday provided an extra $8bn to subsidize the cost of insuring those with preexisting conditions, though with few details about where the money would go.

What would not change

Both the ACA and the GOP proposal allow offspring to be covered by their parents’ insurance policies until they are 26, which was another of the breakthrough of the ACA.

And under the new bill, insurers would still be barred from setting annual and lifetime limits on how much they have to pay out for an individual.

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