The Trump administration renewed its attack on the Affordable Care Act this week, arguing in a legal filing that the entire law should be thrown out.
Earlier efforts to repeal the law failed, but Republicans have chipped away at key provisions of the program better known as Obamacare, such as the tax penalty people were required to pay if they did not buy insurance. Skimpy health plans the law limited have become more readily available, the open enrollment period for individual health plans has been shortened, and funds to help states enroll people through government-based insurance exchanges including healthcare.gov have been slashed.
Last year, a Texas-based lawsuit argued that without the tax penalty, the individual mandate is unconstitutional and the entire ACA should go. The Trump administration initially said only parts of the law should be eliminated. But after a Texas judge ruled that Obamacare should be pitched out, the administration agreed.
The lawsuit could ultimately go to the U.S. Supreme Court. In the meantime, the ACA remains the law of the land. But if President Donald Trump and his supporters get their way, here are some of the consequences, nationally and locally:
The Urban Institute estimates that 20 million people — including 858,000 in Pennsylvania and 595,000 in New Jersey — would lose health insurance if the health law were repealed. The law made coverage more accessible by allowing more people to get Medicaid, creating insurance exchanges with income-based subsidies for people who buy private insurance independently, and barring insurers from raising rates because of age, gender, or health.
The ACA enabled states to expand Medicaid eligibility to an additional 12 million people by raising income limits on the public insurance program for the poor. Under the law, states pay for 10 percent of the additional cost and the federal government pays 90 percent. States would be unlikely to cover that entire cost, the New York Times reported. The Urban Institute estimates that 12 million adults and three million children would lose Medicaid coverage if the health law is repealed.
As the opioid epidemic has raged, Medicaid expansion has allowed at least 760,000 people to get into treatment — about 40 percent of people with opioid addiction, according to the Kaiser Family Foundation (KFF). Private insurance is also required to cover addiction treatment under the law, but KFF found that people with Medicaid were twice as likely as private insured individuals to have received treatment in 2016.
The ACA bans insurers from denying coverage to people with a preexisting condition, agreeing to cover them but not their ailment, or charging a much higher rate. Half of adults under age 65 have what could be considered a preexisting condition — such as cancer, heart disease, asthma, diabetes — and may be forced to go without insurance if the law is struck down, either because they can’t find coverage or can’t afford it. Andrea Deutsch, the mayor of Narberth who has type 1 diabetes, told The Inquirer last year about her years of difficulty finding an insurance plan that would accept her prior to the ACA.
The ACA mandated that most health plans cover a list of 10 essential health benefits with no additional co-pays or cost sharing. The list varies somewhat among states, but typically includes coverage for pregnancy, mental and behavioral health, primary-care checkups, and a range of preventive tests, such as mammograms and colonoscopies. Even with the law’s protection, women routinely meet their plan’s deductible and out-of-pocket maximum during a pregnancy. And screening colonoscopies to detect colon cancer — required to be covered even when a polyp is removed — are a constant source of angst and cost for patients.
One of the most popular provisions of the ACA allowed young adults to remain under their parents’ health plan until age 26. The eventual transition to their own health plan can be jolting, as one New Jersey man found out when the employer health plan he was newly using had a high deductible that left him with a sizable hospital bill. But the rule has helped college graduates saddled with school loans get their footing in their first career without forgoing health insurance and the Pennsylvania Insurance Department estimates 89,000 young adults have taken advantage of this provision. Without the law mandating coverage, insurers and employers would need to decide whether to continue offering the benefit.
If the number of people without insurance rises, so would the amount of care that hospitals and doctors provide without payment. The demand for uncompensated care, which includes bad debt from unpaid bills and charity care written off by a health system, would increase 116.8 percent in Pennsylvania, to $3.4 million, according to the Urban Institute. Demand for uncompensated care would rise 100 percent in New Jersey, to $2.7 million.
The ACA tightened restrictions on short-term, limited-duration health plans, which are much cheaper than comprehensive health insurance because they have fewer benefits and aren’t required to cover preexisting conditions. The health law limited their duration to three months, a rule the Trump administration has already nixed, enabling the plans to cover individuals for 364 days. If the ACA were eliminated, these plans could be even more aggressively marketed.
The ACA improved prescription-drug coverage for people with Medicare by phasing out the “doughnut hole” coverage gap. Prior to the law, seniors were responsible for the full cost of their medications when they reached their initial coverage limit. The ACA limited the portion of the cost seniors in the coverage gap pay for medications, saving Pennsylvania seniors an average of $1,000 a year in medication expenses, according to the Pennsylvania Insurance Department.