The Affordable Care Act: Unfinished Business

June 24, 2021

Office of Government Relations

EPPN Health Care Series Part 3

Sanctify, O Lord, those whom you have called to the study and practice of the arts of healing, and to the prevention of disease and pain. Strengthen them by your life-giving Spirit, that by their ministries the health of the community may be promoted and your creation glorified; through Jesus Christ our Lord. Amen.

-Prayer for Doctors and Nurses, Book of Common Prayer pg. 460

The Supreme Court recently turned back a third challenge to the Affordable Care Act (ACA), ensuring that the law will continue to help Americans access more affordable health care. The Affordable Care Act, in existence for the last decade, has become integral to the American healthcare system. Thanks to the ACA, millions who previously could not afford insurance have access to affordable, quality health care. All Americans benefit from the ACA’s private insurance regulations, which prohibit annual and lifetime coverage caps and ban discrimination and price increases based on pre-existing conditions. Black and Hispanic populations had the highest uninsured rates prior to the ACA’s passage. Thanks to the ACA, those groups have made the largest gains. The uninsured rate for Black adults dropped from 24.4 percent in 2013 to 14.4 percent in 2018, while the rate for Hispanic adults decreased from 40.2 percent to 24.9 percent. These improvements should be celebrated for the millions of lives they have made better.

Yet much more needs to be done.

Persistent issues with the ACA

While the ACA has undeniably improved the overall picture of American health care, the United States continues to face significant health insurance gaps. Since the ACA came into force, fewer American adults go uninsured, but more Americans are underinsured than ever. Of the 194 million U.S. adults aged 19 to 64 in 2018, an estimated 87 million, or 45 percent, were enrolled in health insurance plans that did not meet all their health care needs. Among Americans who were continuously insured through all of 2018, roughly 44 million were underinsured due to high out-of-pocket costs, including co-pays and deductibles. Job loss and an economic recession due to the coronavirus pandemic have caused millions of Americans to lose their job-based health insurance, with some workers switching to marketplace or Medicaid coverage and others becoming uninsured.

Medicaid expansion take-up remains a major challenge. Because of the 2012 Supreme Court ruling, NFIB v. Sebelius, states are free to accept or reject the ACA policy allowing states to open Medicaid insurance to any citizen with an income at or below 138% of the federal poverty level. This ruling led to a patchwork. While 38 states and the District of Columbia have implemented Medicaid expansion since 2014, 12 holdout states remain. Among them are two of the four most populous states: Texas and Florida. Nearly 1 million eligible Floridians and 1.4 million eligible Texans lack Medicaid coverage due to the intransigence of their state governments.

During its four-year term, the Trump administration took several steps to weaken and destroy the Affordable Care Act. The Tax Cuts and Jobs Act of 2017, signed into law by President Donald Trump, effectively eliminated the ACA’s individual insurance mandate, which required Americans to either carry health insurance or face a tax penalty. The Trump administration also slashed funding for advertising and outreach encouraging eligible Americans to sign up for ACA coverage. They allowed states to add work requirements and co-pays to low-income Medicaid expansion populations and stopped providing cost-sharing payments designed to entice private insurance companies to continue participating in the ACA health insurance exchanges.

The former administration also tried and failed to repeal large portions of the ACA during the 115^th Congress when the Republican Party controlled both chambers and intervened in a court case brought by the State of Texas in 2020 asking the Supreme Court to invalidate the entire Affordable Care Act. As noted, on June 17, 2021, the Supreme Court rejected the case brought by Texas, ruling that the state lacked standing to bring the suit, thus upholding the ACA for the third time.

President Biden’s proposals to improve health care

During the 2020 campaign, President Joe Biden’s platform included a wide array of proposals to strengthen and expand access to affordable health care. Then-presidential candidate Biden proposed to expand ACA coverage to non-Medicaid expansion states. He also advocated reducing ACA premiums for those on the health insurance exchanges, lowering the Medicare eligibility age from 65 to 60, and implementing a public option on the exchanges that would provide Medicaid-like coverage in competition with the private health insurance companies.

The president accomplished one of his campaign goals through the American Rescue Plan. The ARP increased subsidies available for ACA exchange plans in 2021 and 2022. If the benchmark plan costs more than 8.5% of income, a subsidy is available, regardless of how high the income is. So, the ARP accounts for the fact that full-price health insurance premiums are much higher in some areas than in other areas and are higher for older enrollees.

The president also restored funding for outreach and advertising ACA exchange plans and opened a special enrollment period so that more Americans could sign up for ACA plans. By mid-May 2021 more than 1 million Americans had enrolled in ACA plans as a result of these efforts. That special enrollment period lasts through August 15.

Take Action

There will be many opportunities in the future to engage on ACA expansion through the Episcopal Public Policy Network. Please sign up for our alerts to stay up to date on healthcare-related action alerts and contact your members of Congress and Senators urging them to expand affordable health coverage to all Americans.

Additional Resources