Updated on May 8, 2017
The Time for Action is Now
The Affordable Care Act (“ACA”) is a central piece of our nation’s health infrastructure, providing insurance to approximately 20 million Americans who would not otherwise have coverage. If the ACA is repealed, many of these people are likely to lose access to medical care, increasing their risk of illness and death.
Public health is charged with improving the health of all people and with reducing health inequities by race, ethnicity, class and other factors. Plans currently proposed in Congress would make it more difficult to achieve this mission by widening chasms in national health outcomes, instead of eradicating them. It’s time to take action.
To that end, Public Health Awakened is creating a series of information briefs about what the Administration’s 100 Days Plan means for health and equity. This ACA info brief is a first in that series.
Public Health Awakened is a group of public health professionals from across the US organizing to support health, equity, and justice under the Trump administration. It is convened and staffed by Human Impact Partners. If you have questions or edits, please email: firstname.lastname@example.org.
What is the Status of Repeal Efforts?
What’s been done so far?
- Congress approved a budget resolution, a first step in repealing and defunding key parts of the Patient Protection and Affordable Care Act (ACA) — also known as “Obamacare” — through a special budgeting procedure known as reconciliation. This approach allows Congress to pass a budget with a simple majority.
- Separately, President Trump signed an executive order to scale back and weaken current use of the ACA.
- Representative Tom Price of Georgia, a leading opponent of the ACA, was sworn in as Secretary of the Department of Health and Human Services (HHS), and the Department proposed a rule that requires additional verification to enroll during “special enrollment periods,” shorten the open enrollment period, and reduce the minimum level of coverage required of participating plans under the ACA.
- Update on 5/4/17: The House passed the American Health Care Act (AHCA) along a near party-line vote, after pulling an earlier version of the bill before it had a full House vote. The Senate is currently putting together its version of the legislation.
Visit The New York Times tracker, Kaiser Health News, or Trump Tracker to get the latest information about the ACA.
Did Congress’ budget resolution, the executive order, or the proposed HHS rule end the ACA?
No, they alone do not end the ACA. They each can undo key pieces of the law if implemented, but that has not happened yet. Key for health professionals to understand and communicate are 2 things: 1) that even a partial undoing of the ACA — through any of these mechanisms — can dramatically affect health; and 2) what actually goes into a replacement plan will be key in how it impacts health and equity.
Understanding the basics of the budget reconciliation process, the major mechanism underway right now, will help advocates defend the ACA. A budget resolution, which is the first step in reconciliation, can only affect federal spending, so it can be used to eliminate subsidies to help people pay for their premiums, funding to states to expand Medicaid programs, and taxes that help pay for those benefits, as well as repeal the individual and employer mandate. However, Congress will need to pursue full repeal or other strategies instead to get rid of ACA components that reconciliation cannot undo — such as provisions of the ACA that allow young adults to remain on parents’ insurance plans until age 26, or prohibit insurers from denying coverage based on pre-existing conditions or from providing certain benefits.
A budget resolution needs 51 votes in the Senate to pass, and must pass the House, but does not need the President’s signature. By contrast, a full repeal needs 60 votes in the Senate to avoid a filibuster, and requires the President’s signature. Prior to the election, members of Congress and the President promised a full repeal of the ACA. This looks less likely right now. However, as the most expansive of the available options, it is important to know about since a full repeal is one way to undo requirements that a reconciliation cannot, as described above.
Where are we in the process?
The next milestone is for the Senate committee to take-up, amend, and vote on the House’s AHCA plan. Then the Senate and House move into committee to resolve differences between the two bills, and then both chambers must vote again on the reconciled bill. The final bill is sent to the President to sign into law.
What Are Possible Effects on Health and Equity?
The effects of ending the ACA — or even undoing key parts of it — depend on what Congress and the President pursue. In the interim, below are ideas of what will likely happen to health if the ACA is dismantled, and how certain communities will be inequitably impacted:
- It will be harder to keep people out of the doctor’s office and community health will get worse. The ACA established the Prevention and Public Health Fund (Prevention Fund), the only dedicated source of federal funding for prevention. This fund allows local health departments to create healthy policies, neighborhoods, and services that keep communities healthy and safe in the first place, helping to avoid costly treatments and long-term care. Dismantling the Prevention Fund would result in every state losing millions of dollars, thus halting and potentially reversing gains made by communities across the country in tobacco use prevention, healthy eating, and active living, among other efforts to improve community health and wellbeing (Trust for America’s Health, 2017a; Trust for America’s Health, 2017b).
- Up to 30 million people are estimated to lose health insurance coverage, with people of color and low-income people among the hardest hit. This includes more than 4 million children and 7 million parents (Urban Institute, 2016; Kaiser Family Foundation, 2016a; Kaiser Family Foundation, 2016b).
- People with medical coverage will pay even more for care. The ACA limits out-of-pocket costs and prohibits lifetime caps on insurance company payments for medical care. Repealing key parts of the ACA — could end these protections for people with individual and employer sponsored insurance, substantially increasing out-of-pocket costs and premiums for individuals and families (Health Affairs blog, 2017).
- Insurance premiums will cost more. The ACA provides tax credits and subsidies for purchasing health insurance, and mandates coverage for all U.S. citizens. If the individual mandate and tax credits are dismantled, premiums will rise and cause healthy people to drop coverage, likely destabilizing the private insurance market and leading to substantially higher costs for all (American Academy of Actuaries, 2016).
- Protections for people with pre-existing conditions—such as diabetes, asthma, and cancer—will be weakened or eliminated. Up to 52 million people with pre-existing conditions may suffer if Congress and the President undo this piece of the ACA. Insurers will be allowed to charge more or deny coverage outright for people with a pre-existing health condition who have any gap in coverage, reverting to a standard practice before the ACA (Kaiser Family Foundation, 2016a).
- Everyday women’s health needs will become pre-existing conditions, which will get less coverage or suddenly cost more. Pregnancy, a history of domestic violence, or experiences with depression could be among the conditions considered pre-existing. Health insurers could also charge women more than men for their insurance by using “gender rating”, which the ACA banned. Preventive services, including birth control, may no longer be covered (National Women’s Law Center, 2016).
- Young adults will lose coverage. The provision allowing young adults to remain as dependents on their parents’ health insurance until age twenty-six could be eliminated. Because of this provision nearly three million young adults gained insurance and improved access to care. Without this provision, millions of young adults will lose coverage and be unable to buy affordable insurance (Health Affairs, 2013).
- Tens of thousands of people will die prematurely due to lack of access. Removing insurance coverage for between 20-30 million people with no replacement could mean an estimated 40,000 deaths (Journal of the American Medical Association, 2015; The Washington Post, 2017).
- Millions of people will lose jobs. Repealing the ACA would cost an estimated 2.6 million healthcare jobs. Economic projections estimate that states’ gross products could decrease by almost $1.5 trillion between 2019 and 2023 (Commonwealth Fund, 2017; Milken Institute School of Public Health, 2017).
- Agencies fighting diseases like Alzheimer’s, diabetes, heart disease, and lead poisoning will be gutted, along with those that promote immunizations. The US Centers for Disease Control and Prevention — the part of the federal government that protects the US from health, safety, and security threats — will lose up to 12% of its budget if Congress and the President repeal the Prevention and Public Health Fund, which is part of the ACA. A repeal would cut vaccine programs by more than 50% and disease tracking by 30%, hampering the response to threats like Zika and foodborne illnesses like salmonella. It would also diminish the ability to track and prevent lead poisoning, like in Flint, MI (American Public Health Association, 2017).
- Federal deficits will increase by billions. Federal deficits will grow by about $353 billion over a decade if Congress and the President repeal the ACA. (Congressional Budget Office, 2015).
- Community health centers will face challenges sustaining their operations. Community health centers serving low-income, uninsured, and rural populations — as well as communities of color — will experience severe financial shocks if Medicaid expansion is dismantled and federal health center grant funding from the ACA ends. Nearly three times as many people gained insurance through Medicaid expansion compared to the exchanges. Undoing the expansion will result in reduced access to vital comprehensive primary care, behavioral health, dental, and case management services for medically underserved and low-income communities across the nation. (Kaiser Family Foundation, 2017; The Hill, 2017; KQED State of Health, 2017, Kaiser Health News, 2017).
- Safety-net hospitals will reduce services or close. Hospitals serving low-income and uninsured populations could lose as much as $41 billion. These dramatic funding cuts will worsen access to care for already underserved and vulnerable communities, and likely put the health of millions at risk (American Hospital Association, 2016, Robert Wood Johnson Foundation, 2017).
What Can Health Departments Do?
- Publicly state or visibly reaffirm your department’s position. Analyze the potential health impacts of proposed repeal and replacement plans, and educate the public and/or elected officials about these impacts. The point is for public health to be vocal in protecting and promoting health. For example, the Minnesota Department of Human Services launched a webpage about the potential impacts of repealing the ACA, including loss of coverage for more than 300,000 Minnesotans.
- Flex your advocacy and lobbying muscles. Many jurisdictions have formal legislative platforms which clarify their policy positions, and some places have paid legislative or lobbying staff. Check with your leadership or legislative/policy staff. Have you taken a position on the ACA or health coverage? If not, can you take one? If you have, coordinate with your jurisdiction’s leadership or lobbyists to ensure your voice is heard by policy makers.
- Mobilize coalitions and professional associations. Work with professional associations such as American Public Health Association, National Association of City and County Health Officials, or state/regional associations such as the Bay Area Regional Health Inequities Initiative, the Public Health Alliance of Southern California, or the Health Officers Association of California to communicate your department’s position to federal legislators.
- Hold free workshops for community members. Public health departments, community organizations, and non-profits could host workshops helping people understand the ACA and how it benefits them as individuals and communities. Host a workshop so community members know where you stand on the issues and to address their concerns.
What Can Public Health Professionals Do?
- Attend Congressional Town Hall events and community meetings. When members of Congress host town hall events and community meetings in home districts starting February 17, participate and ask tough questions about their plans to protect the ACA. Visit Organizing for Action’s Toolkit for guidance on how to do this during the Congressional recess. Identify yourself as a public health professional. If they are on record to repeal the ACA, ask how they are going to manage the loss of coverage, loss of prevention funding, and loss of life that will result.
- Reach out to elected officials — repeatedly and often. Write letters with health colleagues through professional organizations like the American Medical Association and American Public Health Association or call and visit the offices of elected officials at the Congressional and local levels. Inform them about what pending decisions will mean for health and equity. The content in this brief can serve as a starting point.
- Get proactive — call for strengthening the ACA. We can improve the ACA. Ideas include:
- providing higher subsidies to people in low and middle-income households
- providing more subsidies such as fixing what is known as the “family glitch” that blocks an estimated 4.7 million families from coverage
- providing a publicly insured plan in all states that competes directly with other options for private health insurance coverage, in the hopes of driving down premiums and underlying health care costs
Read up on the evidence, become part of the discussion, and join others in advocating for strengthening instead of dismantling the Act. Put another choice on the table. For ideas to consider about how to improve the ACA, see The Century Foundation, 2015. Look for opportunities to partner with other groups or agencies with similar goals.