Give Me a Crash Course in . . . the US healthcare debacle

What’s all this about the US healthcare system?

The Republican Party's plan to repeal and replace Obamacare, the healthcare system that Barack Obama introduced as US president, in 2010, lay in ruins this week after it failed to get enough support for its proposal in the United States Senate. With Republicans holding 52 of the 100 seats, it could afford to lose the support of only two members (with the US vice-president casting a deciding vote). On Monday night, as President Trump was wining and dining seven Republican senators at the White House, two others announced they would not support it, bringing to four the number who opposed the Bill. The top Republican in the senate , majority leader Mitch McConnell, was forced to abandon the vote.

Hang on. I thought there was an agreement on this a few months ago

Yes, but that was in the other chamber in Congress, the House of Representatives. They agreed a new "American Healthcare Act" in May, prompting Trump to hold a celebratory press conference with smiling congressmen in the White House Rose Garden. This time the president was not so keen to get involved. "I'm not going to own it," he said on Tuesday as the plan collapsed.

Why did the plan fail?

Despite Republicans' controlling both houses of Congress and the White House, the party was deeply divided on healthcare. On the one hand, conservative senators, such as Rand Paul, believed the reforms did not go far enough and would still lead to too much government spending on healthcare. On the other hand, moderates, such as Susan Collins, were worried about the impact on poorer constituents, in particular through cuts to Medicaid, the federal programme for low-income Americans that expanded in some states under Obamacare. The plan was never going to keep all sides happy.

Who’s to blame?

Almost immediately the blame game began. Mitch McConnell is a seasoned operator, and many blame him for rushing through a vote on healthcare without any substantive public debate or hearings. He also underestimated the concerns of senators in states, such as Nevada, Ohio and West Virginia, that would be particularly affected by healthcare changes. Others are blaming President Trump, who was disengaged in the process, leaving it to the senate Republican leadership. Instead of trying to convince the public and the party of the benefits of healthcare reform, the president instead chose to concentrate on his "Made in America" week and showed little interest in the minutiae of the complex proposal.

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Weren’t there big problems with Obamacare, though?

Yes, initially. The introduction of the Affordable Care Act, almost seven years ago, was beset with difficulties, not least the problems that affected healthcare exchange websites across the country. But while premiums rose for many, millions of people got healthcare for the first time. Polls in recent months show that support for Obamacare has been increasing. There are still problems – premiums are continuing to rise for some people, while insurers are threatening to pull out altogether from some states. Defenders of Obamacare say part of the problem is the uncertainty around the Obamacare replacement.

What happens next?

McConnell has said he intends to hold a procedural vote soon on a 2015 Bill that would repeal Obamacare but delay its replacement. He currently does not have the support, however. The next step might be some kind of joint effort by Republicans and Democrats to come up with a compromise. At the moment Obamacare remains the law of the land, but Trump’s comments that Republicans should “let Obamacare fail” have worried many. Technically, the administration could cause difficulties for Obamacare by perhaps withholding subsidy payments to insurers or not advertising the annual sign-up period for the programme. For millions of Americans the future of healthcare looks as uncertain as ever.