Republicans are closer than ever to freeing the nation of the program that Ben Carson called "the worst thing since slavery": the Patient Protection and Affordable Care Act (aka the ACA aka Obamacare). Donald Trump himself has labeled President Obama's signature health care program, which extended health insurance to twenty million people, "a disaster" and promised a "full repeal." Though Trump seems to warm to the program the more he finally learns what it is, his transition website still vows to repeal, possibly as soon as Inauguration Day. GOP leaders are practically giddy; Paul Ryan, who once refused to speak his name as a candidate, now hails Trump's arrival as president.
If you're one of the 156 million who gets insurance through your employer, you may think this installment of So What the Fuck Happens Now? doesn't apply to you. After all, many of the ACA's troubles, such as increasing premiums, aren't things people who have insurance through work need to stress about: Their premiums have been rising at "historically slow rates." But if Trump makes good on his repeated promises to repeal the program, it most certainly will affect you. Here are five ways how.
People Will Cling to Jobs With Insurance
What's worse than being stuck in a job you hate because you can't find a better one? Being stuck in a job you hate because you are terrified of losing health insurance. This phenomenon, known as job lock, used to trap approximately 11 million Americans in jobs they'd rather leave. But they had no choice: No job, for many people, meant skipping a doctor's appointment or not filling a prescription or falling behind on medical bills. Now, you can leave your job, for whatever reason, and get healthcare through one of the exchanges, a choice that's increasingly made by young parents who want to take time off. That's not how it was before the ACA, though. "In the old days, you could leave your job and find yourself uninsurable," said John McDonough, a Harvard public health professor and a key player in the 2006 Massachusetts health reform. Without all the features of the ACA in place, it may be that way again.
Pre-Existing Conditions Will Make a Comeback
Before the ACA, the people most likely to be stuck in job lock had a chronic illness (or a family member with one). The reason is that pre-ACA, insurers didn't have to cover people with pre-existing conditions—illnesses, such as heart disease or diabetes or cancer, that you had before you applied for coverage. These types of conditions are super common. The Department of Health and Human Services calculated that 82 million people who get insurance through their employer have one. Now, that might not currently describe you. But the bad news is that as many as 30 percent of people without a pre-existing condition will develop one in the next eight years. The good news is that the ACA prohibited insurance companies from refusing to cover you or charging you a higher premium. Bad news again: A repeal of the ACA would bring us back to a time where people who need health insurance the most will have a hard time getting it.
And while Trump says he wants to save the ban on pre-existing conditions, he also wants to repeal the reason why the ban works: the individual mandate. Without a mandate for everyone to buy health insurance, there will not be enough healthy people (who don't use health insurance often) to balance the costs of sick people (who use health insurance a lot). That's one problem with ACA exchanges right now—too few young healthy people ("young invincibles") are signed up to cover the costs of sicker people. When that happens, premiums rise, which scare away even more healthy people, only worsening the problem. It is called a death spiral—and, without some serious alternatives, that's what may happen if Trump keeps the ban on pre-existing conditions but eliminates the ACA.
You'll Lose Benefits You Didn't Even Realize Obamacare Gave You
Even if you are someone without any pre-existing conditions, you probably still take advantage of the ACA. That's because the ACA requires your insurance to offer ten essential health benefits, from emergency services to prescription drugs, if you work somewhere with fewer than 50 employees. (Large employers tended to offer this coverage already.)
Employers, no matter the size, must also cover preventive services for all adults and children (like immunizations and depression screening and HIV testing) as well as services specifically for women, including prevention against two of the biggest threats to otherwise freewheeling healthy young women: pregnancy and violent men. Right now, one of 18 forms of birth control must be covered for free and pregnant women must receive folic acid supplements and gestational diabetes screening at no cost. Women are also able to receive free domestic violence screening and counseling. But mainstream Republican plans to repeal and replace Obamacare often seek to drive down costs by gutting these benefits.
Your Coverage Will Max Out More Quickly
Since essential health benefits are by definition, well, essential, you can't max out: There is no annual or lifetime limit on them. That applies to employers both small and large. Before the ACA, you may not have even known there was a cap until you ran into it. But if your child is born prematurely and has serious medical needs or if you are diagnosed with cancer, it is easier to burn through $1 million than you might think. For the next few months, at least, essential health benefits include hospitalization and rehabilitation—things you don't know you need until you desperately need them. "In reality, people who get struck by trucks very rarely anticipate it," said Ann Marie Marciarille, a health law attorney and professor at University of Missouri-Kansas City. "How quickly you could go from bad things don't happen to me to oh something bad happened to me."
Everyone Around You Will Be Less Healthy
Even if you never switch jobs and never need a doctor, you should still care about a future without Obamacare. Christine Eibner and a team at RAND found that Trump's plan to repeal the ACA means 19.7 million will lose their insurance. Of course, there are plenty of altruistic reasons why you should care about that number: A 2009 study found that 45,000 people died every year from a lack of insurance. And since the ACA was passed, more people get heart transplants and more women detect cervical cancer early, to name just two others.
But there's also a completely selfish reason to care: If you are someone who leaves your home and interacts with other humans, humans who serve you food and sit next to you on the train, you should want them healthy, too—and that means access to a doctor and prescription medicines and vaccines. "That's the self interest," explains Don Berwick, former Administrator of the Centers for Medicare and Medicaid Services in the Obama administration. "People who can't get healthcare are more likely to be of risk to others. You're better off if your neighbor is healthy."
UPDATE 11/21/16: An earlier version of this story said that 89 million Americans who get insurance through their employer have a pre-existing condition. The correct number is actually 82 million.