Republicans need to reach a challenging consensus on many difficult points if they want to fulfill President Trump’s commitment to provide better coverage with more affordable premiums and lower deductibles. Currently, this seems unreachable, as a senior policy expert explains in JAMA.

“[T]he president and Republicans seeking to replace the Affordable Care Act (ACA) face very difficult political and philosophical choices,” writes Stuart Butler, PhD, a senior fellow in economic studies at the Brookings Institution in Washington, DC. 

“It was evident from the internal backlash to the recent Republican House committee bills that there is a deep divide among Republicans on these choices.”

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Among the plethora of decisions Republicans face in designing an alternative to the ACA, Dr Butler outlines three tough issues: deciding what coverage means, choosing a subsidy approach, and determining how to insure people with chronic illnesses.

Defining “coverage” is crucial to replacing the ACA and also a point of division between most Americans and insurers. The former group believes coverage should apply to routine costs, but insurers want coverage to apply only to “ruinous costs,” explains Dr Butler.

Among Republicans, two popular proposals for providing coverage at lower costs include trimming back the “essential health benefits,” or allowing families to buy cheaper insurance from anywhere in the country. Some Republicans criticize the first idea for removing coverage, such as hospital stays and prescription drugs, while others say the second idea will not work because insurance is typically connected to specific hospitals and physicians, making out-of-state coverage inaccessible.

Another “deep divide” among Republicans is deciding how to construct subsidies. In order to bring down costs of coverage, Republicans will need to either infuse large sums of money or retain ACA-related taxes, which fiscal conservatives oppose. 

Yet another contentious issue Republicans will need to resolve among themselves is how best to provide coverage for individuals with pre-existing illnesses. One option is to continue with the ACA policy that spreads the cost of premiums across the entire population. However, some Republicans believe that this can lead to artificially high premiums for healthier individuals as well as for sicker ones.

The second option is to place high-cost individuals into a separate subsidized insurance risk pool, a proposal most Republications do not accept because the cost to government would be too high, explains Dr Butler.

“As my colleagues and I have pointed out, there are certainly ways to craft an alternative to the ACA that might appeal to many — though not all — Republicans,” he concluded. “But that task is indeed complex, and requires a constructive consensus among Republicans that is currently lacking and may be unattainable.”


Butler SM. “Why Replacing the ACA Has Republicans in a Tizzy.” JAMA. 2017;317(15): 1514-1515. doi:10.1001/jama.2017.3700