Conservative state officials, in conjunction with the Trump administration, have launched an all-out attack on health care in the United States. They have brought a suit to overturn the entirety of the Affordable Care Act (ACA), which would have serious consequences for nearly every American who has health coverage, whether through their employer, the individual market, Medicare, or Medicaid. And they found a partisan judge who, last Friday, proved willing to ignore the rule of law and help them advance their political agenda through the courts.
For now, the ACA remains the law of the land. But if the partisan decision in Texas v. United States is upheld, the consequences could be devastating. The Urban Institute estimates that overturning the ACA would result in 17 million more Americans being uninsured in 2019—in addition to coverage reductions that would occur due to the elimination of the individual mandate penalty. Millions of American families could be left without access to health care—and without the financial safety and peace of mind that health insurance provides. Overturning the law would also have serious negative effects on public health and drug development and would shorten the life of the Medicare trust fund. Moreover, it would provide a major tax break to the wealthiest Americans, insurance companies, and drug manufacturers.
Supporters of the decision have talked about this as an effort to end “Obamacare,” which may cause some people to mistakenly believe it only affects those who obtain coverage through the individual marketplace. Nothing could be further from the truth: Virtually no American’s health care coverage would be safe from the effects of this decision. Here are just some of the impacts that this decision, if upheld, would have.
Risks for people who obtain coverage through their employer
- Lifetime and annual limits on coverage: Polling shows that without the ACA’s ban on lifetime and annual caps on benefits, firms would choose to reinstate limits on coverage. Tens of millions of workers and dependents could face annual or lifetime limits.
- Loss of coverage for young adult children: The ACA requires employer plans that cover dependents to include young adults up to age 26. More than 2 million young adults have gained coverage under the ACA’s dependent coverage provision.
- Loss of free preventive services, including contraception: The ACA requires preventive services—such as immunizations; screenings for cancer, diabetes, and depression; and well-child visits—to be available at no cost to the patient. Womensave about $250 annually thanks to the lack of cost sharing for contraception.
- Elimination of rebates to cover excessively high premiums: The ACA requires insurers to provide rebates if they overprice premiums relative to actual medical costs. Under the ACA’s medical loss ratio provision, insurance companies paid back $344 million in 2016 to people with employer coverage.
Risks for people who receive coverage through Medicare
- Increases in premiums and out-of-pocket costs: Elimination of the ACA would increase some beneficiaries’ premiums, deductibles, and copayments in Medicare Part A and Part B; overturning the law would eliminate Medicare savings, and premiums are based on program spending.
- Cost sharing for preventive services such as mammograms: Under the ACA, Medicare provides preventive services and covers a yearly wellness visit at no cost to the patient.
- Possibility of falling back into the prescription drug coverage gap: The ACA narrowed the Part D coverage gap and was on track to completely fill it by 2020. Without the ACA, many seniors could face higher costs for prescription medications.
Risks for people who receive coverage through Medicaid
- Loss of coverage under the Medicaid expansion: About 12 million people are covered under the Medicaid expansion, which was funded mostly by the federal government under the ACA.
- Higher costs for preventive services such as children’s vaccines: The ACA provided a financial incentive for states to provide preventive services to Medicaid beneficiaries free of charge, which a number of states currently utilize.
- Fewer options to receive care in homes and communities: The ACA provided new options to states to allow elderly enrollees and enrollees with disabilities to receive care in their homes. If the law is overturned, more enrollees will be forced into institutional care.
Risks for people who buy insurance on their own
- Loss of tax credits that make coverage affordable: Nearly 9 in 10 enrollees in the ACA marketplaces receive premium tax credits. Without the ACA, enrollees would lose financial assistance toward monthly premiums, as well as funding that helps lower deductibles and copayments.
- Increased costs or denial of coverage due to pre-existing conditions: Without the ACA, individual market insurers would be allowed to charge more, exclude coverage benefits, or turn away people based on medical history. More than 133 millionAmericans with pre-existing conditions could be subject to discrimination if they ever needed individual market coverage.
- Increased costs for older enrollees: The ACA limits how much more insurance companies can charge older people for coverage relative to younger ones. Without the ACA’s protections, the elderly and near-elderly would see their premiums rise
The legal reasoning behind the lower court’s decision to overturn the ACA is so poor that it has been decried by even some of the most strident conservative legal critics of the law—including those who have backed the previous efforts to overturn it through the courts. Congress has tried and failed to repeal the ACA, and voters in the midterm elections made it clear that they care about keeping protections for pre-existing conditions. Yet the court’s ruling has been approvingly cited by conservative political officials, including President Donald Trump. As such, the decision is best understood not as a legal opinion but instead as a policy preference pursued through the U.S. judiciary. That preference could not be clearer: to give the country’s wealthy and special interests massive taxes cuts—and pay for them with everyone else’s health care.