US & Canada

Why is Obamacare so controversial?

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Media captionWhat do Americans think of Obamacare today?

So near, yet so far - just a couple of Senate votes stand between Republicans and their goal of toppling Obamacare.

The Patient Protection and Affordable Care Act, known as Obamacare or the ACA, is the largest overhaul of the US healthcare system since the 1960s. What does it do, and why is it controversial?

What does the law do?

Its aim is simple - to extend health insurance coverage to some of the estimated 15% of the US population who lack it. Those people receive no coverage from their employers and are not covered by US health programmes for the poor and elderly.

To achieve this, the law requires all Americans to have health insurance, but offers subsidies to make coverage more affordable and aims to reduce the cost of insurance by bringing younger, healthier people into the medical coverage system.

It also requires businesses with more than 50 full-time employees to offer health insurance.

The law creates state-run marketplaces - with websites akin to online travel and shopping sites - where individuals can compare prices as they shop for coverage. Some states have chosen not to participate in the ACA, and their residents can shop on a marketplace run by the federal government.

In addition, the law bans insurance companies from denying health coverage to people with pre-existing health conditions, allows young people to remain on their parents' plans until age 26, and expands eligibility for the government-run Medicaid health programme for the poor.

The law aims eventually to slow the growth of US healthcare spending, which is the highest in the world.

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Media captionWhat is "Obamacare", and why are Republicans against it?

Why do conservatives oppose the law?

Republicans say the law imposes too many costs on business, with many describing it as a "job killer". However, since the implementation of Obamacare, jobs in the health care sector rose by 9%.

They have also decried it as an unwarranted intrusion into the affairs of private businesses and individuals.

The party and a veritable industry of conservative think tanks and advocacy groups have fought the law since Mr Obama first proposed it in 2009 at the start of his first term in office.

After the law was passed in 2010, Republicans launched several legal challenges. In 2012 the US Supreme Court declared it constitutional. It also featured in another Supreme Court case in 2016, when employers argued both against the provision that says companies have to provide birth control and the work-around that allowed the federal government to provide birth control to employees who worked at companies who did not want to provide birth control. The court did not issue a ruling, instead ordering both sides to try to find a compromise.

During Mr Obama's presidency, the House of Representatives, controlled by the Republicans, took dozens of symbolic votes to repeal the law and forced a partial government shutdown over the issue. Republicans in state capitals have also sought to undermine it in various ways.

But Republicans are on their way to overturning Obamacare after the House passed a revised version of a healthcare bill.

The Senate is now considering its own plan, which is hanging in the balance.

Obamacare v Republican plan compared

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Media captionThe BBC's Mark Mardell assesses the potential legacy of Obamacare

Who benefits?

It's estimated that 22 million would lose medical insurance if Obamacare were repealed. Provisions of the law make care accessible to those who had previously been shut out. The uninsured rate has dropped by 5% since the programme began.

Some of the more popular provisions include:

  • Children can stay on their parent's health care plan until age 26
  • No one can be denied insurance for a pre-existing medical condition
  • Companies can no longer charge women more than men

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Image caption The success of the law will depend on how many younger people sign up

What are Obamacare's flaws?

As the law has been implemented there have been certain sections that work better than others, and some that cause problems for consumers. The Obama administration and Democratic members of Congress have tried to push through fixes that they say would alleviate these problems; the Republicans say the flaws are evidence of a failed programme.

Some of the bigger problems include:

  • The Supreme Court's 2012 ruling found the ACA constitutional, but also struck down a provision saying states had to change how they administered the government health programme Medicaid. Under Obamacare, states were supposed to expand the number of people who qualified for Medicaid, which had been reserved for the poor, and in return the federal government would provide the states more funding. The court said states could choose not to participate in Medicaid expansion. As a result, poor and working-class families who don't qualify for Medicaid find themselves having to pay for private insurance.
  • Insurance companies are backing out of participating in Obamacare because fewer Americans than anticipated are signing up; that in turn raises insurances costs for everyone, which then further drives down participation. For some middle-income Americans, the subsidies available for buying Obamacare policies are not generous enough and the fines for not having coverage are too small to encourage them to enroll in plans.
  • Premiums are to rise by an average of 25% in 2017. This increase was predicted at the start of the law, and government subsides to help pay for insurance will also increase. But those who should be covered by the Medicaid expansion aren't eligible for those subsidies.