Prior to passage of the ACA, most low-income adults could not receive Medicaid because income-eligibility limits were downright draconian in most states—well below the current federal poverty level (FPL) of $11,880 a year for an individual. In a blatant gesture of discrimination, federal law excluded non-elderly, non-disabled adults without dependent children entirely from Medicaid eligibility. How sick you were, what health crisis you were facing, did not matter. If you suffered, you suffered. If you died, you died, as an estimated 20,000 to 45,000 Americans did each year because they did not have health insurance. That had become the American way.
The ACA began to change that. With Medicaid expansion, the ACA went a long way toward increasing access to health care for many of America’s forgotten poor, near poor, and disabled. The expansion made 11 million non-elderly adults with incomes up to 138 percent of the federal poverty level ($16,394 a year for an individual) newly eligible for Medicaid, with no or very-low-cost premiums, leaving them responsible only for other nominal health-care costs. It opened the door to Medicaid for adults who had no dependent children. And it expanded Medicaid eligibility for more people with disabilities. That not only made them healthier; it also protected them from lives of forced institutionalization. Medicaid is the primary payer for the cost of long-term support services that are critical to the ability of low-income people with disabilities to live, work, and be active in the community; private insurers and Medicare provide precious little support for these or related services.
The ACA also brought more of the uninsured into the health-care market by giving a financial leg up to people who earned too much to be eligible for Medicaid but still much less than would enable them to buy private insurance independently. It enabled those with incomes from 100 percent to 400 percent of the federal poverty level ($11,880 to $47,520 for individuals, $24,300 to $97,200 for a family of four) to buy health insurance on the public exchanges with the aid of premium tax credits—as long as they didn’t have access to a qualified plan through an employer. An estimated 85 percent of the 11 million people who bought health insurance on the state or federal marketplaces did so with the aid of tax credits that lowered their premiums. In addition, more than 6 million of the lowest-income people, those with incomes from 100 percent to 250 percent of the FPL, also became eligible for cost-sharing reductions, which cap out-of-pocket costs like deductibles and co-pays.
The structure of the ACA extended health insurance to 20 million formerly uninsured low- and moderate-income people, sending our uninsured rate to a record low of less than 9 percent. While that has been an enormous achievement, controversy accompanied the law from the start. It was passed without a single Republican vote. Major computer snafus made the inaugural sign-up for individual policies on the federal exchange a disaster. In time, premiums rose for those buying without credits or subsidies, as high as 145 percent in one location. But premiums on the individual market had been rising pre-ACA too, up 20 percent in 2010 over the previous year. In fact, according an analysis by Brookings researchers, average premiums in the individual market actually dropped significantly upon implementation of the ACA, even as coverage improved. The combined amount a person could be responsible for in deductibles and co-pays with the ACA climbed as well: In 2016, the ACA capped those out-of-pocket maximums for all insurance plans on and off the exchanges at $7,150 for an individual and $14,300 for a family. But deductibles had been on the upswing, too; Kaiser reported that more than a quarter (26 percent) of the people who bought their own insurance in 2010 faced a $5,000 or higher annual deductible. Finally, the number of insurers willing to participate in the exchanges dropped precipitously in many locations, and many people could no longer find the doctors they trusted in their networks.
With people just beyond the cutoff for Medicaid or premium subsidies being required to pay full freight for their health care, some resentment was inevitable. One Kaiser survey focusing on the experiences and opinions of those who buy their own health insurance within or outside the exchanges found that the majority of those who got a tax credit (58 percent) were more likely than those who did not get a tax credit to feel they benefited from the law (even though they did, from such features as no-cost preventive care and requirements that insurers cover 10 essential services). Another Kaiser poll found that, while 50 percent of the public thought low-income people were better off under the ACA, only 27 percent thought those who bought their own health insurance were better off.
Newly eligible Medicaid recipients came in for resentment, too. In late December last year, Kaiser held six focus groups with Trump voters in three Rust Belt states (Pennsylvania, Ohio, and Michigan). Three groups were held with those on Medicaid and three with those who had marketplace insurance with subsidies. Some of those with marketplace insurance, especially those battling severe health problems, saw the subsidies as insufficient and felt left behind by the law. Some, wrote Kaiser President Drew Altman in The New York Times, “saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it.” But, despite their resentment, reported Kaiser, those participants felt that expanded Medicaid coverage “was important and should be retained.”
In fact, an unanticipated consequence of the ACA may well be a change in the American mindset about government involvement in health-care provision. The American public’s position on Medicaid appears to be gradually shifting from a grudging acceptance of what has been seen as an expensive, unearned handout to a greater recognition of Medicaid’s crucial place in our social safety net. By 2005, pre-ACA, nearly three-quarters (74 percent) of adults said Medicaid was a very important government program, ranking close behind Social Security (88 percent) and Medicare (83 percent). However, as the authors of a seminal review of 25 years of public opinion on health-care policy published in 2006 observed, “Medicaid is often discussed both positively and negatively. It is seen as the country’s safety net program for low-income people, but also a program that is becoming too expensive and is threatening the stability of future federal and state budgets.” As a result, they reported, polling in 2005 found that 61 percent of respondents believed that Medicaid was in a financial crisis or had serious problems; 44 percent favored reducing the number of people qualifying for the program as one solution.
Contrast that to the responses to the ACA’s expansion of Medicaid—a program that today covers over 70 million children, adults, people with disabilities, and seniors, one in five Americans. A just-released Kaiser tracking poll found that 84 percent of those polled believed it was important for states that expanded Medicaid with federal funds to continue to receive those funds, including 69 percent of Republicans. While only 12 percent of Americans said they wanted to see Medicaid funding decreased, nearly half (48 percent) wanted funding to stay the same and more than a third (36 percent) wanted funding increased. Faced with Republican proposals to replace open-ended Medicaid funding to states with limited block grants, nearly two-thirds of Americans (65 percent) said Medicaid “should continue largely as it is today, with the federal government guaranteeing coverage for low-income people, setting standards for who states cover and what benefits people get, and matching state Medicaid spending as the number of people on the program goes up or down.”
As for those premium tax credits based on need, there have been complaints, both from those who make too much to receive them and from those who receive them but feel they are insufficient. Still, no one is suggesting abolishing them. A Kaiser poll from November of last year found that 80 percent of those polled favored providing financial help to low- and moderate-income Americans who don’t get insurance through their jobs to help them purchase coverage—including 67 percent of Republicans.
But an even more telling finding emerged in January from a Pew Research Center survey. Asked if it is the responsibility of the federal government to make sure that all Americans have health-care coverage, 60 percent of Americans said yes, the highest percentage in nearly a decade. While far more Democrats than Republicans agreed with that statement, there were significant changes by income: A majority of Republicans (52 percent) with incomes under $30,000 agreed with the proposition (up from 31 percent in 2016), as did over a third of Republicans making $30,000 to $74,999 (up from 14 percent in 2016). Those making the most (over $75,000) agreed the least: 18 percent, up from 16 percent the year before. Even though a majority (67 percent) of Republicans said that the government does not have a responsibility to ensure health-care coverage, more than half (56 percent) said it should continue both Medicare and Medicaid.
Despite all of the controversy that has grown around the ACA, the most recent polls show that the health-care law has reached its highest approval level ever, 54 percent in the latest Pew Research Center poll, and another high, 48 percent, in the latest Kaiser poll. The message may well be that, despite the ACA’s shortcomings, a growing group of Americans don’t want the federal government out of the health-insurance business; they want it to do a better job.
This picture speaks to a powerful coalition in the making. By guaranteeing coverage to a much larger share of the American public through Medicaid, and by convincing Americans of the justice implicit in providing financial assistance to those who cannot afford health insurance on their own, the ACA began to move us closer to a commitment to universal health coverage. While those words have become hopelessly politicized, what they refer to, according to the World Health Organization, is simply a system whereby “all individuals and communities receive the health services they need without suffering financial hardship.” Ours is a patchwork system, but it is a system nonetheless. In terms of paying for that system, interestingly, while there is widespread resistance to the ACA mandate that fines those who don’t sign up for insurance—viewed favorably by only 35 percent of Americans—there has been widespread acceptance of the current system of paying taxes for guaranteed care under Medicare (70 percent in 2015 when the program turned 50).
The Republicans’ new American Health Care Act (contained in two bills, one from the House Energy and Commerce Committee, the other from Ways and Means) would repeal major provisions of the ACA that made health insurance a reality for those 20 million people, while leaving an estimated 28.5 million people who still have no health insurance, mostly low-income families with at least one worker, untouched.
It would greatly diminish opportunities for people to receive Medicaid at all and for that coverage to be adequate. It would end the current federal support for Medicaid expansion in 2020. It would turn Medicaid into a one-size-fits-all program, replacing open-ended federal payments to states with fixed payments capped per person, which may or may not meet a person’s actual health-care needs. And it would make it impossible for Medicaid recipients to use their insurance at Planned Parenthood, because the legislation bans Medicaid payments to “prohibited entities,” a description tailored in the legislation, without naming it, to Planned Parenthood.
The proposed law would end the cost-sharing subsidies that help very-low-income Americans pay deductibles and co-pays. It would replace the ACA credits based on need with credits from $2,000 to $4,000 based on age alone, which would only begin to phase out for earners above $75,000. People could put more money into their health savings accounts, which benefit only higher-income people. Obamacare fees that helped support the health-care expansion would be repealed, like those on health-insurance companies and manufacturers of brand-name prescription drugs. And the legislation would eliminate the requirement that larger companies provide their full-time employees with affordable insurance as well as the individual mandate. However, it would replace the individual mandate with a back-door penalty—a 30 percent surcharge on premiums for anyone who lets their insurance lapse.
The Congressional Budget Office has not yet provided the numbers; we do not know how many people will gain or lose coverage as a result of this legislation or what the program will cost. Yet the two House committees reportedly plan to vote on the bill even without those estimates, and hope to get it to the full House for a vote before their Easter recess begins on April 7.
At their town-hall meetings and in the streets, Republican lawmakers have witnessed the angry backlash against their disorganized efforts to repeal Obamacare, which led some prominent Republicans these past few months to express grave concerns about the risks to consumers, the insurance industry, and their own political lives. “We’d better be sure that we’re prepared to live with the market we’ve created,” Representative Tom McClintock of California was quoted in The Washington Post saying at a closed-door meeting back in January. “That’s going to be called Trumpcare. Republicans will own that lock, stock and barrel, and we’ll be judged in the election less than two years away.”
We cannot know now if the emerging cross-class coalition will hold, if ordinary people will challenge Republican efforts to protect the wealthy and corporate interests while leaving the poor, near poor, and struggling middle-class to once again fend for themselves. What we do know is that with the ACA we took a few small steps into a future inhabited by the rest of the developed world, which sees health care as a right. To go back to the bad old days when empty pockets meant living in terror of an unexpected illness, unrelenting suffering, and early, preventable death would be nothing if not a national shame.
Author: Angela Bonavoglia