A blue-collar and red-blooded American, my father skipped higher education in pursuit of a career as a highly skilled tradesman.  He made a livable wage with excellent employer-sponsored health benefits that covered my younger brother's cancer treatments when he was diagnosed with Lymphoma at the age of fifteen.

Eventually, the economy that has been edging out working class Americans for years caught up to my father, forcing him into cycles of unemployment and lapses in health insurance coverage.

He lost coverage, but my brother didn't lose his cancer. Before the Affordable Care Act (ACA), those facing unemployment could extend their benefits only under Consolidated Omnibus Budget Reconciliation Act (more commonly known as COBRA). COBRA required the unemployed to pay the full premium price of coverage without subsidies and with a clock ticking down on an eighteen month window to find a job or say a prayer.

Catastrophic illness took its toll on my family. We lost our savings. We lost our home. We were robbed by the U.S. health care system.

As a millennial, I grew up watching my father struggle to keep employment and bore witness to an economy with dwindling job opportunities for those without higher education. This likely explains why millennials possess the most education of any generation to date. Yet job security still eludes us. Many millennials entered the job market during one of the worse recessions in U.S. history. The recession is over, but the economy continues to recover slowly, leading to lingering unemployment for long periods for many and low wages in the face of high student debt. This lack of job security translates to lack of health insurance security.

Employer-based insurance is an important cornerstone of the U.S. health system, and it remains the most common form of coverage. We need an economy that makes affordable employer-based insurance widely available. But we also need options for the times when this coverage is not a choice.

The ACA includes provisions that give the piece of mind that comes from knowing insurance is there if you need it. Young adults can now stay on their parents plans until they are twenty-six. Subsidies are offered through COBRA and the Health Insurance Marketplace for private health plans. Medicaid expansion now covers more people. And those with pre-existing conditions don't have to worry about being denied coverage when joining a new plan.

The ACA includes many consumer protections, but it is far from a perfect piece of legislation. According to a 2014 survey from the Commonwealth Fund, there remain an estimated 23% who are underinsured. This means people have coverage but don't use it because they can't afford to.  People on individual plans are more likely to be underinsured, but underinsurance among those on employer-based coverage has doubled since 2003. This is a problem.

But the solution to this problem is not pulling the plug and dismembering the ACA. Replacement options proposed by President-elect Trump and other Republicans rely heavily on health savings accounts (HSA). HSAs are no better at protecting against catastrophic illness than other forms of savings. In 2015, the average HSA balance was only $1,844.

Health insurance is complex. And after six years, the ACA has become so integrated with the healthcare system that significant and rapid changes would cause organizational and economic chaos. Many parts of the ACA protect consumers, and our lawmakers should keep them. Even some unpopular parts, like the individual mandate, should be kept because they are essential to the goal of affordability.

Rather than upheaving our system in a way that makes hardworking Americans vulnerable, Congress should thoughtfully and carefully improve the ACA by finding ways to expand both access and affordability when employer-based coverage isn't a choice.


Rosie Mae Henson, MPH, a 2016 graduate of the Dornsife School of Public Health at Drexel University, works for the School's Urban Health Collaborative.


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