Affordable Care Act: Rolling Back Coverage, Part III

Nov 19

The Patient Protection and Affordable Care Act (ACA) has endured a number of policy adjustments and legal challenges since its inception in 2010. Speculation regarding potential changes for 2025 include the reduction of Medicaid expansion programs and eligibility.

Expansion programs are a critical resource for lower earning Americans to obtain healthcare, and rollbacks could have a lasting impact on the health and wellness of our society. According to the Department of Health and Human Services, 45 million people are enrolled in expansion or market place plans offered within the ACA, which is the highest on record.

Medicaid Overview

In order to qualify for coverage, your household income must be below 138% of the federal poverty level (FPL). In recent years, Medicaid expansion programs have also extended coverage and tax credits to households earning between 100% and 400% FPL.

Federal Medicaid mandates dictate a number of high-level requirements states must follow, in addition to state specific coverages and policies.

Federal Mandates Include:

Inpatient and outpatient hospital care
Physician services
Lab and x-ray services
Nursing home and personal care services

There may be no costs associated with covered medical expenses, and some subscribers must pay a small co-pay.

Medicaid Unwinding

During the COVID-19 pandemic, the federal government restricted states from validating eligibility for Medicaid and the Children’s Health Insurance Program. According to the American Medical Association, the combined program numbers went from 71 million in late 2020 to more than 94 million by 2023. In May 2023, the public health emergency expired and states were again permitted to validate eligibility. According to the Kaiser Family Foundation, as states began to rollback or unwind coverage, more than 25 million people lost coverage.

The COVID-19 Medicaid unwinding should provide insight to potential eligibility changes the new administration is considering for the ACA and Medicaid. Principley, where did the people go? Were some able to return to post-pandemic norms and afford care? Or did a percentage determine healthcare was too expensive, and decided to forgo coverage altogether?

Regardless of our government construct, major changes will take time to implement and sustain. At the same time, three potential elements are causing uncertainty, including:

An outright repeal of the ACA or weakening its policies
Cap or reduction in Medicaid funding (terminating subsidies)
Further restricting Medicaid eligibility

Obligations

The age-old debate of government influence in our day-to-day decision making received ample attention in the 2024 election cycle. Beyond influence, what role does the government play in providing access to affordable healthcare?

The World Health Organization published government responsibilities related to healthcare. In part, they contend the role of the government is to:

Provide good-quality health services, that are accessible and affordable to all who need them.
Ensure policies, frameworks and standards for health and well-being are in place and acted on
Make sure the cost of using services do not put people at risk of financial harm
Give benefits to people who need them as this can help to protect against financial harm

Counter opinions indicate the government has no role in healthcare and it remains the responsibility of the people. Assigning responsibility without considering socioeconomic construct is short sided, and does not address the complete picture.

Yes, this goes beyond healthcare. If it’s the responsibility of the people, then we also need to consider:

Paying a living wage
Enabling access to affordable housing
Offering healthcare and prescription drugs at a reasonable costs based on the earning power of a given individual
Extending managed and preventative care at reasonable costs (chronic illness management, mental health support, vaccines, etc.)
Offering reliable and consistent access to public transportation
Implementing, funding, and sustaining community-centric programs (job training, childcare, nutrition, and medical)

According to the Centers for Medicare and Medicaid Services, national health expenditures were approximately $4.5 trillion in 2022, or $13,493 per person, which is 17.3% of the gross domestic product. Other notable figures include:

Prescription drug spending increased 8.4% to $405.9 billion in 2022; compared to 6.8% in 2021
Out of pocket spending grew 6.6% to $471.4 billion in 2022
The largest shares of total health spending was the sponsored by the federal government: 33% and households: 28%

Despite investing trillions, our societal health is not a global leader. According to the Commonwealth Fund, among high-income countries, the United States has the:

Highest death rate among avoidable or treatable conditions
Lowest life expectancy at birth
Among the highest in suicide rates
Highest rate of people with multiple chronic conditions

An additional analysis by the organization also reported our healthcare system was rated last overall in equity, access to care, and outcome measures.

Symptoms not Causes

Health and wellness should should not be reserved for those with money, power, and influence, nor should a select group of individuals determine who is worthy of care. Our modern society bears responsibility to provide collective care for the health and well being of our people.

Removing the Medicare safety net for the most marginalized of our neighbors will not address shortcomings in our trillion dollar healthcare investments, nor catapult our country to higher percentages of equity or access to care. It requires creative policies and progressive solutions from a comprehensive team of healthcare professionals, economists, policy experts, and community members.

Ensuring widespread access to affordable care for all Americans could be a unifying concept, however community members must ignore political and societal rhetoric in order to influence lasting change. In an age of continued division, equity and accessibility to healthcare could serve as a unifying concept for those willing to take the risk.