Why are we talking about this? Because after the individual mandate installed by the Affordable Care Act (ACA)—which required a majority of Americans to enroll in some form of health insurance or pay a fine—was eliminated in 2017, senators and some states have been arguing about the validity of the ACA. Certain states now want the ACA overturned, because the claim is that removing just one part makes the entire law null and void. A Supreme Court hearing is scheduled for November 10, 2020.

So, what is at stake and will an ACA repeal impact health care access and affordability? This is what the ACA promised:

  • Health insurance exchanges
  • Medicaid expansion
  • Preexisting conditions protection
  • No out-of-pocket (OOP) costs for preventive care, including free vaccination
  • Extension of dependent care till 26 years
  • Reduction in prescription drug costs for beneficiaries
  • Essential health benefits
  • Marketplace premium subsidies

What Will Happen If the ACA Is Repealed?

According to the Robert Wood Johnson Foundation (RWJF), 20 million people are at risk of losing coverage if the ACA is overturned. The most affected would be:

  •  Low-wage workers
  • Young adults (under 26) on their parents’ insurance plan
  • Nonelderly adults without a college degree

Minorities could see an increase in uninsured rate. If the law had been repealed in 2019, nonelderly Hispanics would have seen a 10% rise in uninsured rate (21% to 31%) and the uninsured rate among nonelderly blacks would have doubled (from 11% to 20%).

Pre-existing condition protections: Provisions within the ACA imposed cost-sharing limits and included essential health benefits—these can be a huge relief for individuals with chronic conditions such as diabetes, cardiovascular conditions, arthritis, etc., because it assures them of comprehensive coverage. A pre-existing condition is defined by health plans as an illness or an injury that a person has prior to enrolling in a new health plan. While President Trump issued an executive order that assures healthcare coverage for individuals with pre-existing conditions, it may not mean much if the law is repealed.

Marketplace premium subsidies: The ACA created health insurance exchanges (also called the health insurance marketplace) in each state as a place for individuals, families, and small businesses to enroll in affordable health insurance. While the exchanges did face some upheaval, with insurers pulling out or offering short-term plans that had minimal coverage, premiums stabilized and even declined in 2019 and 2020, according to the RWJF analysis. The advantages of this marketplace included:

  • Over 10 million insured
  • Subsidized premiums
  • Comprehensive coverage benefits
  • Protection against extreme OOP costs

The marketplace is an ideal option for employees whose workplace does not offer insurance or those who are unemployed and seeking health coverage. Overturning the ACA would leave these individuals and their families in limbo—an estimated 9.5 million workers (many in low-wage occupations positions) and 5.2 million family members gained health coverage via the marketplace and Medicaid expansion between 2010 and 2015.

Essential health benefits: Under the ACA, all individual and small group health plans sold through, and outside, the exchanges had to provide minimal essential benefits to all enrollees with no cap on annual or lifetime spending. These benefits include:

  • Hospitalization
  • Ambulatory services (visits to doctors and other healthcare professionals and outpatient hospital care)
  • Emergency services
  • Maternity and newborn care
  • Services to treat mental health disorders and problems with substance abuse
  • Prescription drugs
  • Laboratory tests
  • Preventive services
  • Pediatric services for children, including dental and vision care
  • Rehabilitative and “habilitative” services

Loss of such comprehensive coverage could lead to patients delaying necessary care because it may be unaffordable.

Medicaid expansion: Widening the eligibility for Medicaid enrollment led to low uninsured rates among low-income populations in several states. It also improved access to care, utilization of medical services, made care affordable, and created financial security for low-income populations. While research is yet to confirm the financial impact of Medicaid expansion at the federal level, state budgets logged savings and hospitals saw a reduction in uncompensated care. By 2015, Medicaid saw a $5 million revenue increase per hospital and uncompensated care reduced by $3.2 million per hospital.

Extension of dependent care till 26 years: This provision of the ACA was built in to address the high uninsurance rate among the young adult population. After the law took effect in 2010, the number of uninsured young adults:

  • Fell by 29% in the moderate-income group and 61% in the high-income group by 2013
  • Fell by 22% by 2014 among low-income young adults after Medicaid expansion

Overall, uninsurance among young adults saw a 37% drop by 2014. Overturning the ACA can negatively impact the insurance rate among the younger population.

COVID-19 and the ACA

With many businesses shutting down or laying off employees during the COVID-19 pandemic, the U.S. unemployment rate has sky-rocketed, making the ACA healthcare exchanges and Medicaid expansion even more significant. Lack of health insurance, if the ACA is struck down and people lose coverage, could impede contact tracing because people may hide their illness and may not get tested out of fear of care costs.

This is the reality facing our nation in the coming months. 

 The information in this article was researched and summarized by Surabhi Dangi-Garimella, Ph.D., Principal, SDG AdvoHealth, LLC. Improving patient access is our mission and we are happy to utilize a variety of experts to carry that out.