Obamacare’s Future: Repeal, Replace or Revise

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While the first attempt to repeal and replace the ACA came up short, it’s anyone’s guess what will happen next. One thing is for sure: This isn’t our first rodeo, and we’d be wise to take a few lessons from history. 

Repeal? Replace? Who will be covered? How will emergency care be affected? As emergency physicians and the public ask questions and anticipate the promised changes in the 2010 Affordable Care Act, a.k.a. Obamacare from the new Trump administration and a Republican-controlled Congress, it may be useful to look at the history of government-sponsored health insurance programs.

Unlike many Western democracies, the United States, despite many runs at universal health insurance, has favored private, commercial insurance with some element of federal and state insurance for the elderly and poor in the form of Medicare and Medicaid. The battle between those who believe that health care is a right and should be funded and guaranteed by the federal government, and those who believe that it should be a private, purchased commodity has been fought in our nation since the early 1900s. Universal health insurance was a post-WWII priority of FDR and later Harry Truman, but was opposed by the AMA, and defeated three times in Congress. Senators and House members did agree on one major boost to medical care—the Hospital Survey and Construction Act, signed into law by Truman in 1946. The law became better known as the Hill-Burton program, and through it billions of dollars went to the cities and hometowns of congressmen to fund new hospitals and their new EDs [1].

A confluence of factors in the 1960s made the eventual passage of Medicare and Medicaid possible. President Lyndon Johnson’s Great Society vision, a Democrat-controlled Congress, and the grudging support of Wilbur Mills, the powerful Chair of the House Ways and Means Committee, launched Medicare and Medicaid in 1965. A key provision of the law was Part B, which was supported by the AMA, other physician groups, and Republicans. Part B provided government–subsidized voluntary insurance for physicians’ fees [1].

The impact of Medicare/Medicaid on the finances of emergency care cannot be understated. The early emergency physicians, who were usually employed by or under contract with hospitals and who usually did not bill for their services, figured out that they could do much better if they formed groups outside the hospital and did their own billing. Physician incomes grew sharply under Medicare/Medicaid. Early groups like the Alexandria Plan physicians and a collaboration of EPs in Michigan were now profitable and able to grow. In the end, the financial boost brought on by Medicare and Medicaid stimulated the overall viability of emergency medicine as a profession, and the subsequent creation of residency programs and the specialty as a whole.

As the elderly and poor now had health insurance, their consumption of health services jumped dramatically. Physician practices became overloaded, with long waits to be seen. The predictable result was that patients showed up in EDs for care with “deferred pathology” from previously untreated conditions [2]. In the five years after Medicare/Medicaid was enacted, annual US ED visits in the now plentiful Hill-Burton hospitals increased from 29 million to 43 million [3]. As it has been in the 50 years since, emergency medicine started out as the back-stop and safety net for unmet medical needs of patients who had no place else to turn.

Unlike in other nations, where universal health insurance was matched with support for increased primary care services, the number of primary care physicians was not proportionately increased post Medicare/Medicaid. In fact, the percentage of non-primary care specialist physicians was increasing dramatically at this time. Part of the incentive to specialize was that in the early years, Medicare Part B paid the full charges of physicians for evaluation, treatment, and procedures. The elderly, previously a low-or-no-pay group, were now a goldmine for specialist physicians.

Like the Affordable Care Act, Medicare and Medicaid greatly increased access to care, and improved the health of millions of people. But Medicare, in particular, required considerable tinkering and revision after its initial roll-out. Cost was a major issue, as in the initial law there were not limits on reimbursement to physicians who could charge “customary fees.” Hospital procedures were reimbursed at a much higher level than those done in outpatient offices. National per capita health expenditures rose sharply from $198 in 1965 to $336 in 1970 [1]. Thus, Medicare and Medicaid as originally conceived and implemented were unsustainable and over the next decade major revisions were enacted that put fee limits in place, reviewed physician utilization, and encouraged the formation of HMO’s and other managed care models.

Many emergency physicians who saw a sharp drop in the percentage of their patients that were uninsured in the past several years will be watching to see if this is reversed by new federal policy. The take home lesson from Medicare/Medicaid in their early iterations is that a complex, multi-faceted law will require analysis, revisions, and new approaches. Like Medicare/Medicaid, the ACA initially focused on access, but has been bedeviled by costs, especially for states that have had a large increase in Medicaid enrollees. Paul Starr, the famous sociologist, notes that federal programs aimed at improving the lives of the population serially go through stages of expansion, equity, and cost-containment [1]. The ACA is just emerging from the expansion phase, has made good gains in equity, but is not adequately addressing cost containment.

Fortunately, previous administrations did not repeal Medicare/Medicaid when problems arose; they revised the programs and made them sustainable. The Trump administration has vowed to repeal and replace the ACA, but would be wise to study the history of public health insurance to see that throwing out the baby with the bath water may not be necessary or financially prudent. Emergency physicians who are in the real world milieu of patients and have been affected by the ACA over the past six years can testify to the positive impact of the law, while offering suggestions on how to improve quality and reduce costs.


  1. Starr, P. The social transformation of American medicine. Basic Books, Inc. Publishers, New York, 1982.
  2. Zink, B. Anyone, anything, anytime – a history of emergency medicine. Mosby Elsevier, Philadephia, PA, 2006. Interview of Karl Mangold, MD.
  3. Data from the American Hospital Association Statistics, 1954-2002 and the American College of Emergency Physicians.

Brian J. Zink, MD is a Professor and Chair in the Department of Emergency Medicine at Alpert Medical School of Brown University. Dr. Zink is also the author of Anyone, Anything, Anytime- a History of Emergency Medicine (Mosby Elsevier, 2006)

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