These would be the most obvious effects if the Supreme Court
ruled the ACA unconstitutional.
By Simon F. Haeder • September 29, 2020
More than 10 years after its passage, the
Affordable Care Act once more hangs in the balance. There have been plenty of
near misses before, including previous Supreme Court appearances and
Congressional votes. Yet in the wake of Justice Ruth Bader Ginsburg’s death,
this time around Republicans may finally be successful in undoing the Obama
Administration’s signature achievement. Hearings before the Supreme Court are scheduled to begin on Nov. 10 on
whether a change in tax law makes the ACA unconstitutional.
The ACA can be improved in many ways, as I have written elsewhere. Yet if the
Supreme Court strikes down the ACA, it
seems unlikely to me that a meaningful replacement will be put in place among
high levels of partisanship in Washington, D.C.
As a result, if the court kills it virtually all Americans
would be affected by the policy reversal, as the almost
1,000 pages of legislative text and ensuing more than 9,000 pages in
regulations have impacted all parts of the American health care
system.
As a health policy and politics scholar who
has published extensively on the ACA, I see the following as the most obvious
effects if the Supreme Court ruled the ACA unconstitutional.
1. Millions of Americans will lose coverage
The
ACA can be improved in many ways. Yet if the Supreme Court strikes down the
ACA, it seems unlikely that a meaningful replacement will be put in place.
One of the key features of the ACA was the expansion of
insurance to millions of Americans. Most of this was achieved through the
expansion of the Medicaid program, America’s safety net
program.
Additionally, the ACA provided insurance market reforms and
subsidies that made it easier to buy health plans for those Americans making
too much to quality for Medicaid.
Millions of young Americans able have been able to also stay
on their parents’ coverage until they turn 26.
More than 20 million Americans will lose
their insurance if the ACA is undone.
2. Many hospitals and clinics may close, especially in rural
areas
Even before COVID-19, many medical providers including
hospitals and clinics were struggling to keep their doors open. This
particularly applied to those located in poorer and more rural areas of the
country. Indeed, hospital closures since 2010 have mostly occurred in
states that have refused to expand their Medicaid program, like Texas and
Alabama. These pressures would be gravely exacerbated with millions of
Americans losing coverage. Closures
affect all community members, whether they have insurance or not, as
residents lose access to hospitals and specialists.
3. Loss of protection for pre-existing conditions
Before the ACA became law, many Americans were frequently turned down when they went to buy insurance.
The insurance carriers deemed them too much of a financial risk due to their
“pre-existing conditions.”
Before passage of the ACA, this practice was subject to a
confusing mix of state and federal laws, regulations and enforcement. Insurers
developed lists of conditions, medications or occupations that
would lead to an automatic denial of insurance coverage.
These “declinable conditions” including diverse issues
ranging from substance abuse to acne. Many insurers also refused to cover
victims of rape, and 45 states allowed the practice for
C-sections. In total, a congressional report found that 425 medical diagnoses have been used to
decline coverage.
It seems likely that exposure to COVID-19 would now also
fall into this category. And, it’s far from certain whether so-called COVID
long haulers would be covered.
4. Loss of some benefits and higher co-pays
Prior to the ACA, it was generally up to each state to
determine what benefits insurance ought to cover. States differed widely in
terms of comprehensiveness. Many did not require prescription drugs or
well-child visits to be included. For example, 62 percent of individuals in the individual market lacked
maternity coverage, and 34 percent lacked coverage for substance abuse disorder
treatment.
The ACA established a floor by generally requiring coverage
to include a minimum set of Essential
Health Benefits. It also required that preventive
services like vaccinations or wellness visits be provided
without any out-of-pocket costs.
Equally important, the ACA eliminated annual and
lifetime coverage limits that insurers commonly imposed. These
restrictions often confused consumers and left them on the hook for large
charges when they got sick and exceeded the limits.
5. Seniors will pay more, and Medicare will be destabilized
One of the biggest ways America’s seniors would be affected
by the undoing of the ACA would be increases in prescription drug costs. Each
year, about 5 million of them experience a coverage gap. This infamous Medicare Part D “donut hole”, which
the ACA moved to close, required seniors to shoulder the full amount of
prescription drugs costs after a certain amount until they reach a certain
threshold.
Adding further costs, seniors, like all other Americans,
would also face more out-of-pocket payments for preventive services.
Early retirees too young to qualify for Medicare will
find it virtually impossible to obtain insurance coverage on their own. Those
with pre-existing conditions would be turned down by the insurance carrier.
Most others would face prohibitively high premiums due to their age.
Eliminating the ACA would also expunge the increase in payroll taxes for high-income earners,
which stabilized the Medicare trust fund. This raises new concerns about the
long-term viability of the entire program.
6. The opioid epidemic will get worse
While the public is focused on the current pandemic, an
opioid epidemic has ravaged the nation for years. It will also likely long
outlast the impact of COVID-19, as more than 20 million Americans suffer from addiction.
The effects are enormous and permeate American communities. The ACA has
allowed hundreds of thousands of Americans to get crucial treatment by
providing them with access to health insurance.
Equally important, the ACA’s
Essential Health Benefit provisions required policies sold in
the individual market to cover addiction and mental health services. As
mentioned before, it also eliminated annual and lifetime limits on these benefits.
7. Women will suffer disproportionately
Few groups have benefited as much from the ACA as
American women, who have gained improved coverage benefits, and
access. Importantly, the uninsurance rate for women dropped significantly, from as much as 17%
prior to the ACA to 11%.
Reduction in uninsurance were particularly pronounced for
Hispanic women and those with low socio-economic status. Both groups saw reductions
by 10 percentage points to 22% and 21%, respectively.
Moreover, the practice of charging women higher premiums
solely based on their gender was banned. Before the ACA, in most states it was
even common to charge a male smoker less than a female nonsmoker for
insurance coverage before passage of the ACA to account for higher levels of
healthcare utilization of women.
Women have also benefited tremendously from the elimination of out-of-pocket cost for
preventive services like mammograms, well-woman visits, domestic and
interpersonal violence screening and counseling.
Pre-existing condition protections have also proven
particularly important for women as they could no longer be denied coverage due to
having had a C-section, being a survivor of breast or cervical cancer, or
having received medical treatment for domestic or sexual violence.
The ACA also ensured that women are guaranteed coverage for pregnancy, maternity and newborn care and
that preventive and prenatal services are now covered free of charge. Similarly, insurers are now
required to provide new mothers with equipment to extract breast milk and the support services to
do so.
Finally, the ACA also supports women in planning their
families by eliminating out-of-pocket costs for contraceptive services. This
reduced the number of women without such benefits more than 20% to 3%.
8. Coal miners and their families will lose benefits
Coal miners and their families will also
experience a significant reduction in benefits if the ACA is reversed in court.
A little-known provision in the ACA greatly
facilitated access to benefits for miners affected by years of exposure to coal
dust now suffering from black lung disease. These benefits would be
eliminated with the ACA. Of course, it would also affect eligibility for many
miners with regard to Medicaid and the ACA marketplaces.
Simon F. Haeder, Assistant Professor of Public
Policy, Pennsylvania State University. This article is
republished from The Conversation under a Creative Commons
license. Read the original article.
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