Today, Donald Trump said "Nobody knew healthcare could be so complicated." That statement went unchallenged for, oh, 42 seconds before media and social media erupted with assurances that many, many people knew healthcare was complicated and had known it for some time.
The problem is for years and years various leaders have been wrestling with a set of incompatible objectives. You have "the healthcare industry" composed of large and small profit-making enterprises, including: insurance companies, pharmaceutical companies, medical equipment manufacturers/distributors, hospitals, clinics, pharmacies, nursing homes, visiting nurse services, doctors, nurses, medical practices, etc. You have American citizens with their disparate incomes and zero control over the prices they are charged for medical services/products, and very little control (for most) over what they earn.
The "industry" wants to be able to profit as much as possible. Citizens want to pay as little as possible. Many citizens literally can't afford to pay much, if anything. Wage stagnation, a problem that has been building for 30 years, means millions of Americans work full-time, often more than full-time, and still can't afford medical insurance (among other things). In 2012 half of Americans had a family income of less than just over $50,000; individuals earned $26,000 or less. That's half of Americans. Gross incomes. Think about it. Add up your utilities, rent or mortgage payments, phone costs, and see how far you can go on $26,000/year (before taxes) or less.
Now, Americans have received their medical insurance through their employers since WWII. But since the 1970's incomes have stagnated for large chunks of the public while medical costs have soared. What to do?
Hmm, well, some countries have socialized their medical delivery, but Americans have been fed a steady stream of propaganda aimed at convincing them "socialized medicine" will be disastrous (paid for by our friends in the profit-making healthcare industry). In 2009 when Congress debated the ACA, polls and surveys showed a strong majority of Americans were against a single-payer system.
Furthermore, something like 7% of America's economy is bound up in healthcare. Millions of Americans are employed in healthcare and many Americans have investments in healthcare-related companies. So, while I absolutely support "Medicare-for-all" I recognize a shift from for-profit to non-profit healthcare would be a massive jolt to the economy. That doesn't mean we shouldn't do it, but if we do, we have to deal with the fall-out. And that's something no one talks about (including Bernie Sanders, who ran on a platform of Single-Payer).
Well then, how about increasing incomes in America so that people can afford insurance? Addressing that question would require pages of discussion. The summary? Republican policies make rich people richer, poor people suffer, and middle-income people stagnate. A small percentage of folks in the top 5% (as opposed to the ultra-wealthy in the top .01%) have seen increased incomes in the last 20 years or so, but most of Americans have endured losses. Recent Democratic policies exhibited an awareness of income stagnation and inequality, and Hillary Clinton's platform offered several prescriptions to help matters, including "improvements" to the ACA. But we didn't get Hillary, we got Donald and the GOP with promises to repeal and replace.
When people think about the ACA they need to understand what the law was trying to do. It was NOT designed to be the most efficient, cost-effective delivery system for healthcare in America. It was designed to provide "affordable" health insurance to Americans with the least disruption to the for-profit system we've had for the last 60 years. It was designed, in other words, to keep the money flowing to the profit-makers while reducing expenses for American citizens. Included were certain guarantees: no pre-existing conditions disqualifications, no lifetime caps, etc. There's a bunch of stuff in the law surrounding various efforts to create efficiencies and reduce/eliminate genuine waste, as well. And insurance companies were mandated to spend 80% of premiums on actual service delivery, versus marketing, etc. But the key was that most people could still get insurance through their jobs and those who couldn't would have a place to go — the exchanges — to get affordable insurance on the "open market". Affordability resulted from subsidies based on income levels.
So, basically, the federal government was putting out subsidy money to keep profits going for providers—corporate welfare. But providers had no objections — they'd take the dough.
Unfortunately, the GOP decided from Day One that allowing the ACA to succeed would be a feather in Obama's cap and they couldn't have that. So they did everything they could to damage the law. They put out a constant stream of misinformation. Several Republican governors refused to accept subsidies from the federal government, which meant their own citizens could not afford coverage. In addition, Republican governors refused to set up state exchanges, which meant the Fed had to create a program to serve these states (i.e., healthcare.gov). This was a massive, unexpected undertaking because Democrats didn't plan for Republicans literally being willing to deny their own citizens medical care out of spite. When the online program first went live it had problems, which GOP members gleefully pointed out, without the slightest shame, even though they had themselves created the problem.
And so it went.
But things began to come together and kinks were worked out and costs started dropping and the numbers of uninsured was dramatically reduced. But the GOP continued trying to repeal the law and continued to rail against it and continued to claim they could do better.
Now that Republicans are in a position to repeal the ACA and replace it with something "better" they are discovering there is no "better" that meets their requirements. Because something, somewhere has to give. Either the for-profit players have to get less profit, or incomes have to dramatically increase for all Americans, or the Fed or states have to provide some form of subsidies, or some combination of all those things must happen. Otherwise, we end up back where we were before ACA: more and more people dying and/or going bankrupt due to medical costs.
Republicans don't want to spend tax dollars subsidizing insurance. They don't want to socialize healthcare. They don't want to increase minimum wage. They want to reduce taxes for the wealthy and starve state and local governments. They want "trickle-down" to work, finally, even though we've been trying it for 30+ years and it hasn't worked. They faced Town Halls wherein constituents told them repeatedly they would suffer if the ACA were repealed without an equal or better replacement.
To repeal without replacing the ACA would be a staggering act of political malpractice.