The Patient Protection and Affordable Care Act (ACA), signed into law in 2010, significantly expanded access to health insurance in the U.S. Also known as “Obamacare” or PPACA, the ACA created health insurance exchanges where people can enroll in insurance coverage that isn’t tied to employment. The federal government operates HealthCare.gov, an exchange that currently covers 38 states, while 12 states and the District of Columbia operate their own exchanges. This new form of coverage offered a measure of security that people with preexisting conditions never had before.
But the Affordable Care Act has faced a multitude of legal challenges over the past decade, with additional cases working their way through the courts. Last year, we spoke with Claire Sachs, founder and author of The Patient Advocate’s Chronicle, about the value of the ACA for people living with Gaucher disease and the effects of repealing the affordable care act. We followed up with her this month to discuss the significance of the ACA during a public health crisis.
Understanding the Affordable Care Act: Focus on the Facts
Between the pandemic and the ongoing political and legal challenges to the ACA, “there’s a flood of news coming out, and the information that’s not science-based isn’t helpful,” Sachs says. For medical information, she advises, “The best thing is to go straight to the source—places like CDC, NIH, or a reputable medical research center like the Cleveland Clinic, Mayo Clinic, and Anderson down in Texas. If you prefer more traditional outlets, just be careful and make sure you’re getting information and guidance that is science-based.”
As for health policy news, Sachs recommends “the proven outlets, like The New York Times, The Washington Post, The Wall Street Journal, Bloomberg, and Forbes… along with science-oriented but lay-person-friendly outlets like Health Affairs and STAT.”
Why is the Affordable Care Act Important During a Public Health Crisis?
“What the ACA does for people with chronic conditions is it requires insurance to cover certain things, the big one being preexisting conditions,” Sachs says. “In the bad old days, even pregnancy was considered a preexisting condition. For those who have Gaucher disease or any other preexisting condition, this essential health benefit requires coverage for disease management.”
“Everyone qualifies for the ACA, especially those who don’t have access to employer-based insurance. And if your income is under a certain level, you will get subsidies through tax credits,” she explains.
During a public health crisis, the ACA provides an additional layer of comfort to people with preexisting conditions. The law is also a safety net for people who are more likely to experience complications from COVID-19 due to specific preexisting conditions, including obesity, hypertension, cardiac conditions, and diabetes. “I think it’s keeping so many of us from panic,” Sachs says.
The Kaiser Family Foundation estimated that nearly 27 million people lost employer-sponsored health insurance in March and April of 2020. Thanks to the ACA, 79% of those people are eligible for coverage through the health insurance exchanges or Medicaid. Healthy individuals who may not have previously worried about health insurance are now in a position to benefit greatly from the safety net the ACA provides.
Effects of the Affordable Care Act on healthcare access
ACA-compliant health insurance plans are required to cover 10 essential health benefits, including preventive care. The ACA has demonstrably improved the health of Americans, particularly pre-Medicare adults ages 50 – 64. Data from the Health and Retirement Study shows that following the enactment of the ACA, people in this age group were more likely to have insurance coverage, self-reported improved health, and were less likely to need care in a hospital or nursing home.
Since older adults and people with certain preexisting conditions are more susceptible to serious complications from COVID-19, preventive care plays a key role in reducing risk. The preventive health benefit will also cover a COVID-19 vaccine, once one receives approval.
ACA-compliant plans must also cover hospitalization and emergency care. People must be willing to seek medical care when they are ill and not hesitate due to financial concerns. This is critical, especially during a public health crisis, as cost concerns factor into the decision of whether to seek care. An April survey by the Commonwealth Fund and SSRS found that 69% percent of adults would consider out-of-pocket costs as “somewhat” or “very important” in deciding whether to get care for COVID-19 symptoms.
When is Affordable Care Act Open Enrollment?
Generally, people can sign up for health insurance coverage through the ACA-created insurance marketplaces during the annual open enrollment period. Open enrollment occurs at the end of a calendar year, for coverage that begins January 1 of the following year. Open enrollment for 2021 coverage for all ACA-compliant plans will take place from November 1, 2020 – December 15, 2020. States that run their own exchanges may extend this enrollment period.
But what happens if you lose insurance coverage in the middle of the year? That’s where special enrollment periods (SEPs) come in.
What qualifies as a special enrollment period?
You may be eligible to enroll in coverage outside of the open enrollment period if you have a qualifying life event. Depending on the event, your eligibility may begin up to 60 days before the qualifying event or extend to up to 60 days after. Qualifying life events include:
- Changes in household, such as getting married or divorced; having a baby, adopting a child, or placing a child in foster care; or the death of someone on your marketplace plan.
- Changes in residence, such as moving to a new zip code or county; moving to the U.S. from a foreign country or territory; moving to or returning from school or work; and moving to or from a shelter.
- Loss of health insurance, due to losing your job, losing eligibility for Medicaid, or losing coverage through a family member.
- Other life circumstances, including gaining membership in a federally recognized tribe, gaining U.S. citizenship, leaving incarceration, or starting or ending a federal service program.
Are there COVID-19 pandemic special enrollment periods?
The federal government and the states that operate their own exchanges have the power to create additional special enrollment periods for circumstances that impact the eligibility of a large number of people. The coronavirus pandemic and the related economic downturn are prime examples.
“The Trump administration didn’t put in place a special enrollment period for the pandemic, but several states have state-based exchanges, and a few put special enrollment in place,” Sachs says.
Of the 12 states and the District of Columbia that operate their own exchanges, all but Idaho offered COVID-19 SEPs, and some announced plans to extend open enrollment in the fall of 2020. SEP enrollment data is not available for every state yet, but California alone enrolled almost 250,000 people during the first half of 2020 since its open enrollment period ended January 31.
Six of the states currently covered by HealthCare.gov are in the process of switching to state-run exchanges. This will allow these states to extend open enrollment and create special enrollment periods if they choose.
Pennsylvania and New Jersey plan to get their exchanges up and running in time for open enrollment in November 2020. Both states project that running their own exchanges will save money in administrative costs, which they will pass on to consumers through lower premiums. New Mexico, Kentucky, Maine, and Virginia plan to open state-run exchanges in the next few years.
Despite the lack of a federal COVID-19 SEP, a June report from the Centers for Medicare & Medicaid Services found that over 487,000 people used the loss of coverage qualifying life event to sign up for coverage through the federal exchange from December 16, 2019 through May 2020. This represents a 46% increase over the same time period in 2019.
There is also a new “Marketplace coverage & Coronavirus” page on HealthCare.gov that outlines the pandemic-related qualifying life events that may allow someone to enroll for coverage outside of the open enrollment period. Qualifying life events are like individual SEPs — anyone who meets the criteria of a qualifying life event is eligible to enroll in marketplace coverage. This page covers scenarios common during the pandemic, including:
- Job change, including job loss, reduction of hours, or furlough resulting in lost employer-sponsored health insurance.
- Change in residence, including college students under age 26 moving back in with parents.
- Qualification for a previous special enrollment period, but missed the deadline due to COVID-19 illness.
Sachs hopes the pandemic is encouraging more healthy people to proactively sign up for health insurance. “I’m hoping people who have had access but didn’t sign up for insurance are now motivated by the possibility of infection [by COVID-19] and realize it’s important to have health insurance.”
Another benefit of the ACA is expanded Medicaid coverage, 90% of which is provided by the federal government. Thirteen of the states covered by HealthCare.gov have not expanded Medicaid, which increases the Medicaid coverage gap in those states.
California v. Texas: The Latest ACA Legal Challenge
In March, the Supreme Court announced that it will hear California v. Texas (originally called Texas v. US), a consolidated case challenging the legality of the Affordable Care Act, during the court’s fall 2020 term.
Back in 2012, the Supreme Court upheld the constitutionality of the ACA in National Federation of Independent Business v. Sebelius. The court ruled that the individual mandate of the ACA, which requires individuals to have insurance or pay a penalty, constitutes a tax, and is therefore within Congress’s power to enact.
The California v. Texas case stems from the Tax Cuts and Jobs Act of 2017, which set the penalty for the individual mandate to zero. Following this, a coalition of Republican state attorneys general, led by Texas, brought a case challenging the validity of the ACA, since the Supreme Court previously ruled it was constitutional because of the individual mandate. If the ACA is constitutional because it is enforced by imposing a tax, and now there is no tax, they argue that the ACA in its entirety is unconstitutional.
The Trump administration has declined to defend the ACA in court. “The administration has proposed lots of hypothetical alternatives to the ACA, but it has not offered any actual policy alternatives,” according to Sachs.
What would an ACA repeal mean for people living with Gaucher disease?
People living with Gaucher disease rely on the ACA’s requirement to cover preexisting conditions and elimination of yearly and annual caps. Disease management involves many medical appointments, some with specialists, and treatment is expensive. If the Supreme Court overturns the ACA, “it could take us back to the dark ages of healthcare coverage. Even with HIPAA standing, you can’t have a gap in coverage. You need to have proof of consistent coverage, or your new insurance could consider any existing health issue as preexisting and deny or delay coverage. It complicates everything,” Sachs says.
Further, people who recover from COVID-19 may struggle to get insurance. “Since it currently appears that COVID-19 may have long-term effects on some organ systems, it may eventually be categorized as a source of chronic disease. If that happens and the ACA were to be repealed, it puts people in a very difficult position because the insurance companies would be allowed to deny or delay coverage of COVID-caused complications due to its status as preexisting,” she says.
Millions of people stand to lose health insurance access and protection for preexisting conditions if the ACA is overturned. This is particularly dangerous during a pandemic and economic recession. “People who lost jobs during this current recession would either need to go on Medicaid or seek care in the ER for everything, knowing that the ER needs to treat you sufficiently so that you are stable enough to go home. But if a patient can’t pay that ER bill, the cost ultimately goes to the taxpayer,” Sachs says.
How you can help protect the ACA
The Affordable Care Act expands access to health coverage, provides critical protections for people with preexisting conditions like Gaucher disease, and requires coverage of preventive and critical care, all of which are essential for a strong public health response to the pandemic. Now California v. Texas has put the sense of security provided by the ACA in jeopardy. Since the case will not be heard until October and will not be decided until next June, it may feel like all we can do is wait and see.
That’s not exactly true. The remedy to a harmful Supreme Court verdict is legislation. As it happens, we are on the verge of what may be one of the most impactful elections in American history. As we approach that election, keep in mind all that we, as patients with expensive preexisting conditions, could lose.
Knowing that, exercise your constitutionally given power and vote. Choose the legislators you think will protect the vital provisions the ACA provides. Sixty percent of American adults have conditions that would be negatively affected by the repeal of the ACA. If we all vote for candidates that will protect it, we will all be able to breathe a little easier at night.
- Avalere – Exchanges May Add More than 1 Million New Enrollees due to COVID-19: https://avalere.com/insights/exchanges-may-add-more-than-1-million-new-enrollees-due-to-covid-19
- CMS – Special Trends Report: Enrollment Data and Coverage Options for Consumers During the COVID-19 Public Health Emergency: https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/SEP-Report-June-2020.pdf
- CNN – Nearly half a million people flocked to Obamacare after losing coverage this year: https://www.cnn.com/2020/06/25/politics/obamacare-enrollment-jobs-trump/index.html
- Families USA – “COVID Coverage” Is Not Enough: The American People Need Comprehensive Health Insurance During the Coronavirus Pandemic and Resulting Economic Crash: https://familiesusa.org/wp-content/uploads/2020/07/COV_255_Comprehensive-Insurance-Fact-Sheet.pdf
- Health Affairs – DOJ, Republican AGs Ask Supreme Court To Strike Down ACA: https://www.healthaffairs.org/do/10.1377/hblog20200626.180922/full/
- Health Affairs – The Supreme Court’s Surprising Decision On The Medicaid Expansion: How Will The Federal Government And States Proceed? https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2012.0766
- gov – Getting health coverage outside Open Enrollment: https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/
- gov – Health coverage rights and protections: https://www.healthcare.gov/health-care-law-protections/
- gov – Marketplace coverage & Coronavirus: https://www.healthcare.gov/coronavirus/
- Kaiser Family Foundation – Eligibility for ACA Health Coverage Following Job Loss: https://www.kff.org/coronavirus-covid-19/issue-brief/eligibility-for-aca-health-coverage-following-job-loss/
- Kaiser Family Foundation – How Many Uninsured Adults Could Be Reached If All States Expanded Medicaid? https://www.kff.org/uninsured/issue-brief/how-many-uninsured-adults-could-be-reached-if-all-states-expanded-medicaid
- New York Times – Millions Have Lost Health Insurance in Pandemic-Driven Recession: https://www.nytimes.com/2020/07/13/us/politics/coronavirus-health-insurance-trump.html
- The Conversation – Obamacare’s unexpected bonus: How the Affordable Care Act is helping middle-aged Americans during the pandemic: https://theconversation.com/obamacares-unexpected-bonus-how-the-affordable-care-act-is-helping-middle-aged-americans-during-the-pandemic-139267
- Kaiser Health News – ‘Pennie’-Pinching States Take Over Obamacare Exchanges From Feds: https://khn.org/news/pennie-pinching-states-take-over-obamacare-exchanges-from-feds/