What will Americans lose if the ACA is struck down?
A new KFF study shows much the landscape of health insurance has changed since the adoption of the Affordable Care Act.
The fate of the Affordable Care Act hangs in the balance, with arguments in the combined cases California v. Texas and Texas v. California set to be heard at the U.S. Supreme Court on Nov. 10. The plaintiffs believe the entire ACA should be struck since the individual mandate was declared unconstitutional by a federal appeals court panel in Texas. The Trump administration sided with the plaintiffs, initially arguing that the mandate could be severed from the rest of the law but ultimately supporting invalidating the law entirely. The passing of Justice Ruth Bader Ginsburg also potentially affects the outcome of a decision that could result in nearly 23 million Americans finding themselves without health insurance.
Related: Voters split on economy, health care as election approaches
In the ten years since it was adopted, the Affordable Care Act has changed the landscape of health insurance in numerous ways, from protecting people with pre-existing conditions to requiring coverage of preventive services with no cost-sharing in private insurance, Medicare, and a newly-expanded Medicaid. The Kaiser Family Foundation analyzed several of those key provisions and measured public attitudes towards the changes the ACA has wrought in American health care.
As of June 2019, there were 14.8 million Medicaid expansion enrollees in the 34 states and the District of Columbia that had adopted the expansion. The 2012 Supreme Court decision in National Federation of Independent Business v. Sebelius found the ACA Medicaid expansion unconstitutionally coercive, essentially rendering it optional for states. Of the 14.8 million enrollees, 12 million became newly eligible under the expansion, including 3.7 million in California and nearly half a million each in Illinois, Michigan, New Jersey, Ohio, Pennsylvania and Washington. A KFF poll found that 57% of respondents found it was “very important” that states retain the option to expand Medicaid coverage for low-income, uninsured adults, while 29% found it “somewhat important.” The poll also found that 66% of those living in non-expansion states would like to see their state expand Medicaid.
According to KFF’s research, about 54 million people (or 27% of the non-elderly population) have a pre-existing condition that would have been deniable pre-ACA. Under the ACA, insurers in the non-group, small group, and large group market must guarantee issue coverage and all non-grandfathered plans are prohibited from discriminating against individuals based on their health status. Nearly 72% of respondents to KFF’s poll say it is “very important” that those provisions remain in place if the ACA is found to be unconstitutional, and 57% were either “somewhat worried” (22%) or “very worried” (35%) that they or a family member would lose that coverage.
The preventive services provisions are also very popular. The ACA mandates that all non-grandfathered group and non-group plans must cover preventive health services without cost sharing. Those services include cancer screenings and pregnancy-related services. As of February 2019, 12.7 million people were enrolled in individual market plans required to provide free preventive services. Additionally, 14.8 million enrollees in Medicaid expansion states received coverage for preventive services in 2019. A July 2019 KFF poll found that 62% of respondents said it was “very important” to keep the no-cost-sharing provision for preventive services if the ACA was struck down, while 27% found it “somewhat important.”
As of the first quarter of 2020, 10.7 million people were enrolled in coverage through the health insurance marketplaces created under the ACA. That number includes 9.2 million who received premium tax credits and 5.3 million who got cost-sharing reductions. This year also saw 26 new insurers entering 18 state marketplaces. While 82% of the public (91% of Democrats, 78% of Independents, and 71% of Republicans) have a favorable view of the idea of the marketplaces, opinions are divided about their efficiency: 45% of respondents say the marketplaces are working well, while 47% say they are not.
There’s far less divergence of opinion when it comes to the ACA’s provision allowing adult children to remain on their parents’ insurance plan up to age 26. KFF’s polling found 51% of respondents saying that provision was “very important,” and 27% said it was “somewhat important.” According to a recent survey sponsored by Getinsured, 34% of uninsured millennials were not aware they could shop for insurance on the ACA marketplace, and 53% of those who were aware of the marketplace did not know about money-saving tax credits.
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