Since the moment it was signed into law by President Barack Obama in March of 2010, opponents of the landmark Affordable Care Act (ACA) have been trying to repeal it. The law is designed to make health insurance affordable and accessible for all Americans. Its basic tenets include coverage of essential health benefits and of people with pre-existing conditions. It also allows children to remain on their parents’ insurance plans until the age of 26, eliminates lifetime and annual coverage limits, and slows the rise of health care costs, among other benefits. In the decade since the act’s passage, the number of uninsured people in the United States has dropped by roughly 20 million. There have been significant increases in doctor visits for low-income people, more people are filling their prescriptions, and average per-person medical debt fell by more than $1,000.
The law also has drawbacks. Its passage caused an estimated 3 million to 5 million people to lose the insurance they had through their employers, who found it more cost-effective to cancel their employees’ plans and pay the penalty. It also raised income tax rates for individual people with incomes above $200,000 and couples with incomes above $250,000, and added an additional Medicare tax to income from investments. Some health insurance companies found it more profitable to operate outside the marketplace, meaning that people with some plans under the ACA had fewer in-network physicians.
For those reasons — plus any number of others, including the fact that the ACA guarantees coverage for preventative health services for women, including contraception — the law has lots of political enemies. Chief among them is President Donald Trump, who ran in 2016 on a platform of repealing it. The ACA has come before the Supreme Court several times, and a new challenge is scheduled to be heard in early November.
The nomination of judge Amy Coney Barrett to the Supreme Court “is putting this pending case into the spotlight in a way it might not have been,” says Capri Cafaro, executive in residence at American University’s School of Public Affairs, “and I think that’s making the public focus more on the role of the ACA, and how affordable and accessible health care impacts their lives.”
It’s more crucial a consideration now, she adds, because if the law were to be struck down, Covid-19 could theoretically become a preexisting condition. The list of other declinable conditions is long, and includes things like past cancers, diabetes, obesity, asthma, anxiety and depression, pregnancy, and even acne. According to one estimate, roughly 27% of non-elderly American adults — or nearly 54 million people — have one or more conditions that could cost them their insurance. “People with preexisting conditions could potentially be denied coverage,” Cafaro says. “Should the ACA get struck down, what’s the impact on access to health care coverage for those with preexisting conditions? That’s become very, very important.”
Robin Rudowitz, co-director of the program on Medicaid and the uninsured at KFF, a health policy-focused nonprofit, says it’s important for voters to remember what things were like prior to the ACA’s passage.
“People don’t remember that, prior to the ACA, people who had preexisting conditions were just priced out of the market and couldn’t purchase coverage,” she says. “There were a lot of people who were uninsured and had no access to coverage options. The ACA was a fundamental change.”
Trump, who has supported proposals in Congress to weaken preexisting condition protections and cap federal funding for Medicaid — which provides coverage to lower-income families and children — also supports repealing the law in its entirety, and has repeatedly pledged to replace it with “a full and complete health care plan,” though no such plan has been announced. He has expressed support for short-term insurance plans that would have lower premiums, but may not cover preexisting conditions or include the basic coverages the ACA calls for.
Trump did sign an executive order stating that it is “the policy of the United States” to provide coverage for individuals with pre-existing conditions — a practice that is already enshrined in law under the ACA. If it were to be repealed, it’s unclear how Trump’s executive order would be enforced.
Another executive order directed Congress and the Department of Health and Human Services to work together to pass legislation protecting patients from surprise medical billing, which can happen due to providers being “out of network” under ACA plans. Any Trump health care plan is likely to also reduce the role of the federal government, leaving states with a larger share of responsibility for funding Medicaid plans. It would also allow states to determine eligibility for Medicaid, and to institute work and education requirements for people to qualify for coverage.
“The current administration has made a lot of effort to limit the scope of financing and coverage,” Rudowitz says. “A Biden administration would build on Medicaid and on the current ACA, and work to expand coverage.”
Biden also supports establishing a government-run public insurance plan, which would provide coverage to a large number of additional low-income residents, and allow anyone — including people on a policy through their employer — to purchase additional coverage. Biden proposes lowering the age of eligibility for Medicare, the national program that covers elderly Americans, from 65 to 60, which could reduce the cost of premiums across the board by shifting many people away from both Medicaid and employer-provided policies.
“There are two very different proposals related to the ACA and coverage expansion,” says Rudowitz. “The plan of the current administration and what Biden would do are starkly different, so I guess we’ll see.”