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How did we get here? Four essential reads on the status of health care in America

House Speaker Paul Ryan at a March 7, 2017 unveiling of the new health care bill called the American Health Care Plan. Susan Walsh/AP

Editor’s note: The following is a roundup of archival stories related to the proposed American Health Care Act and the Affordable Care Act, commonly called Obamacare.

Turmoil around health care policy is reaching a fever pitch in Washington. But politicians have been working for decades to provide health insurance to the tens of millions of people in the U.S. who go without it. This number includes millions not covered by employer-sponsored insurance, those who were excluded for coverage because they had prior conditions or those who lacked the money to pay for health insurance on their own.

The Affordable Care Act, passed under President Barack Obama in 2010, made it illegal for insurers to deny coverage because of preexisting conditions. It also provided subsidies to millions who could not afford to buy insurance on their own. And to further help the poor, it expanded Medicaid to cover more lower-income people. To help offset new costs, the law required that all people of a certain income buy health insurance. This was called the “individual mandate.”

These changes brought about dramatic changes to the health care market, explained economists Darius Lakdawalla of the University of Southern California and Anup Malani of the University of Chicago:

These insurance expansions are projected to cost roughly US$1.4 trillion over the first 10 years after the ACA’s implementation and cover between 22 and 32 million additional Americans. This expansion in coverage represents one of the, if not the, signal achievement of the ACA.”

The law was decried by Republicans who quickly dubbed it “Obamacare.” The law was challenged twice in the Supreme Court, with opponents arguing the individual mandate was unconstitutional. It withstood both challenges. Insurance experts, such as J.B. Silvers from Case Western Reserve University, explained why the mandate was essential from a business perspective.

This so-called individual mandate also guaranteed business for the insurance companies, because it led healthy people into the risk pool.

The implementation of the law had problems. Premium prices rose, and many insurers dropped out of the law’s marketplaces. Hillary Clinton vowed to fix the broken parts, but Donald Trump campaigned to replace what he called “the disaster that is Obamacare.”

Now, with Republicans in control of the House, Senate and presidency, they are working to create a plan that would be cheaper and provide better health insurance than the ACA did. On March 7, 2017, House Speaker Paul Ryan introduced their version of health care reform, the American Health Care Act, calling it an “act of mercy.” This bill has been criticized for providing tax cuts to the rich and because it would leave millions once more without insurance, detractors say.

Megan Foster Friedman detailed how the proposed law would affect health care for the poor:

In addition, beginning in 2020, the bill would shift Medicaid to a per-capita cap. This would be a fundamental restructuring of the Medicaid program, affecting over 70 million people.

The Congressional Budget Office announced March 13 that, by its analysis, 24 million would lose health care in the next 10 years.

Health services expert Bill Custer from Georgia State University explained how there could be other effects as well: even middle-class people could lose insurance. Without the individual mandate, insurers will have a harder time being profitable. If that happens, individual markets in some states could collapse.

But when healthy individuals choose not to purchase health insurance, insurers are left with costs greater than their premium income. That forces insurers to increase their premiums, which in turn leads healthier individuals to drop coverage increasing average claims costs.

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