The next time somebody tells you that Obamacare is failing, read them this list of ten ways that Republicans worked to make it fail.

1. CO-OPs short-changed from the start 

Let’s start by considering the ACA’s Consumer Operated and Oriented Plans, or CO-OPs. Early drafts of the ACA called for $10 billion in federal grants for the CO-OP program. But insurance lobbyists and conservative lawmakers insisted on $6 billion in loans instead of $10 billion in grants, restrictions limiting CO-OPs to the individual and small-group market (and not the more stable and profitable large-group market), and limitations stating that the federal loan money could not be used for marketing. 

The ACA passed in 2010 and the CO-OPs were to be up and running in the fall of 2013, in time for the first open enrollment period. But during 2011 budget negotiations, $2.2 billion was cut from the CO-OP funding. And then during the “fiscal cliff” negotiations at the end of 2012, another $1.4 billion in CO-OP loan funding was eliminated. 

Those Republican led changes undermined and ultimately killed most of the original 23 co-ops.

Just as the GOP planned.  

2. Day One legal challenges 

On March 23, 2010, the same day the ACA was signed into law, attorneys general from 14 states began the process of challenging the ACA’s individual mandate via the court system. A total of 26 states eventually joined in the lawsuit, which went all the way to the Supreme Court. 

3. Refusal to take ACA’s Medicaid expansion 


The ACA scheduled Medicaid expansion to take effect at the beginning of 2014. But at that point, half the states had opted against expansion, despite the fact that the federal government paid the full cost of expansion for the first three years (and nearly all of it after that). Even now, in 2017, there are still 19 states that have not expanded Medicaid. 

That obviously has a negative impact on people living in poverty, but it’s also deleterious to the individual insurance markets in those states. 

This is of course had far reaching implications, and was perhaps one of the most heartless attacks levied by the Republicans.

4. Obstruction of enrollment efforts Most states have opted to let HHS do the heavy lifting on exchange creation. Although there has been some shifting over the years, there are currently just 12 fully state-run exchanges (11 states and DC). The rest of the states use HealthCare.gov, either as part of the federally run exchange, or as an enrollment platform for a federally supported state-based exchange.

By January of 2014 seventeen states had passed laws that restricted the navigator's ability to help residents understand and enroll in the new plans.

The Judicial system invalidated many of those laws, but ultimately the damage had been done.

5. Efforts to invalidate premium subsidies 

In King v. Burwell (formerly King v. Sebelius), plaintiffs argued that premium subsidies could not legally be distributed in states that didn’t establish their own health insurance exchanges. The Supreme Court ruled in the government’s favor in 2015, upholding the legality of premium subsidies in every state. 

It’s notable, however, that Indiana, Oklahoma, Alabama, Georgia, Nebraska, South Carolina, and West Virginia all joined amicus briefs in support of the plaintiffs in King v. Burwell. Those states – all of which use the federally run exchange – supported the idea that premium subsidies should not be available in states that use the federally run exchange. 

 These attempts ultimately failed in the courts, but they were yet another attempt to undermine the validity of the new law and to shake the voters confidence in its survival.

6. A legal challenge to cost-sharing reductions 

The ACA’s cost-sharing subsidies are an essential part of making health care accessible for lower-income Americans. For people with incomes up to 250 percent of the poverty level, cost-sharing reductions (CSRs) are automatically added to silver plans, making the coverage much more robust than it would otherwise be. 

 The federal government reimburses health insurers for the additional coverage provided by the CSRs; those reimbursements totaled $7 billion in 2016. But in 2014, House Republicans, led by then-Speaker John Boehner, filed a lawsuit against the Obama Administration, challenging the executive branch’s authority to reimburse insurers for CSRs, as they had not specifically been appropriated by Congress. 

Once again this attack ultimately failed but it continued to shake confidence in the viability of the ACA.


7. Undermining of ACA’s risk corridors 

Risk corridors were a three-year program designed to keep the individual markets stable during the early years of ACA compliance. The idea was to take money from insurers that ended up with lower-than-expected claims, and send it to insurers that ended up with higher-than-expected claims.

Senator Marco Rubio crafted language to undermine this program, and attach it to a must pass bill, which ultimately caused smaller insurers to flee the ACA and co-ops to close down.


8. Trump’s executive order 

 On January 20, within hours of his inauguration, Trump signed his first executive order. The order directs federal agencies to: 

“exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.” 

This allowed people to more easily avoid the tax penalty for not having insurance, and that of course also undermines the incentive to get insurance.

9. AHCA’s effect on market stability 

The House of Representatives has also worked to undermine the individual mandate via the American Health Care Act (AHCA) that they passed in early May. 

The legislation would eliminate the individual mandate penalty retroactively to the start of 2016. And while it would instead institute a 30 percent rate increase (or health-status underwriting in states that opt for that) for people who don’t maintain continuous coverage, that provision wouldn’t take effect until after the 2018 open enrollment period is complete. 

As passed by the House, the AHCA undermines insurers’ efforts to keep healthy people in the risk pool. Unsurprisingly, the Congressional Budget Office estimated that 4 million people would drop coverage in 2017 if the AHCA were to pass. Half of them are in the individual market, despite the fact that less than 6 percent of the U.S. population has coverage in the individual market. 

The bill has not passed the Senate, and likely never will, but the confidence of the health insurance consumer has now been irreversibly shaken and of course this has negatively impacted the number of people purchasing the insurance.

And finally.....


10. GOP refusal to work on bipartisan fixes 

The ACA has been in effect for seven years, and Republican lawmakers have been trying to repeal or defund it for seven years. (You can see some of their efforts here.) But they have been mostly unwilling to work together with Democrats to make any significant changes to the ACA to make it work better. 

This of course was perhaps the most egregious and disingenuous effort by the Republican party. 

President Obama and the Democrats knew full well that the original law as written had multiple bugs, but believed naively that the Republicans would come around when they saw how much good it was doing and help to sand off its rough edges and make it a highly successful piece of legislation that would benefit the American people for decades to come.

If President Obama had one glaring flaw it was that he always wanted to see the good in people, and failed to recognize the depths that the Republicans would sink to destroy this bit of legislation which, if successful, they feared might signal the end of their political party.

Ultimately the Republicans chose to sacrifice the lives of their constituents, for the survival of their party.

So there you go. The next time that somebody claims that Obamacare is broken, you can now show them step by step who broke it.

(The ten examples come to us courtesy of the fine folks over at Health Insurance.org.)