• In The Trenches

    ACA's Vital Progress Again in Jeopardy

    "Little by little, one walks far."
    -- Peruvian proverb

    File folders with a tab labeled Health Insurance

    The Patient Protection and Affordable Care Act remains one of the most hotly contested and politicized laws in modern history. Since its passage in 2010, Congress has sought to repeal or modify the law more than 70 times.

    Two weeks ago, against counsel from HHS Secretary Alex Azar, the administration filed a brief calling for the ACA to be invalidated, joining a case brought before the Supreme Court by Republican officials from Texas and 17 other states. The latest case is in response to a ruling last December by a federal appeals court panel, which ruled that the ACA's individual mandate was unconstitutional after Congress zeroed out the financial penalty for not having coverage. The case was sent back to a lower court to determine whether the law could continue to stand without the mandate.

    Amid all of the legal and political machinations throughout the past 10 years, let's not forget that the ACA provided some important protections and modernization to the health care system. As the Supreme Court prepares for oral arguments this fall that could ultimately upend the law entirely, these changes could be in jeopardy.

    Protecting Patients

    The ACA made health care more accessible for individuals previously locked out of coverage. Before the law's passage, it was not uncommon for insurers to decline coverage to individuals who were anticipated to incur higher health care costs. This could be based on age or previous medical history. Similarly, insurance carriers were permitted to exclude coverage of certain conditions. For example, if an individual had a history of cancer, insurers could exclude coverage of that condition, leaving those beneficiaries exposed financially to the full cost of any treatments required. Insurers could also cancel coverage without explanation. Some would wait until expensive claims came in and then would review enrollment applications to find clerical errors or discrepancies that would allow them to retroactively cancel coverage. The ACA banned these egregious and predatory practices, marking an important win for consumers.

    Expanding Medicaid

    A central goal of the ACA was to expand access to health care for all Americans. One of the most meaningful ways that it achieved this was by expanding Medicaid to individuals with incomes up to 138% of the federal poverty level. Although initially included as a requirement, a June 2012 Supreme Court ruling in National Federation of Independent Business v. Sebelius allowed states the option of not expanding Medicaid. Still, three-fourths of states have chosen to expand this coverage. In addition, the ACA required streamlined eligibility, enrollment and renewal processes regardless of whether states chose to expand, which ensured that eligible individuals didn't face unnecessary barriers and disruptions. This expansion has gone a long way to address health care coverage-related disparities.

    Fostering Innovation

    CMS has always had the authority to test payment models through demonstration programs, but the Center for Medicare and Medicaid Innovation, created by the ACA, was designed to achieve higher health care quality and lower overall costs in government programs such as Medicare, Medicaid and CHIP. The law granted HHS more tools and funding to design, test and implement models that demonstrate the ability to achieve savings while maintaining or improving quality of care. Previously, congressional approval was required to expand successful models, which led to years-long delays and sometimes prohibited implementation altogether. Should the ACA be invalidated, the future of models such as Comprehensive Primary Care Plus, Direct Contracting and Primary Care First could be in jeopardy.

    Making Coverage Meaningful

    Before passage of the ACA, many insurance offerings in the group market were relatively slimmed down. Benefits excluded many necessary services and imposed annual and lifetime limits that caused financial ruin for many Americans who needed care beyond what their policies offered. The ACA eliminated annual and lifetime limits to protect policyholders facing significant health care needs. It ensured that all plans offered in the individual and small group market covered, at a minimum, health care people actually need, including

    • ambulatory patient services;
    • emergency services;
    • hospitalization;
    • pregnancy, maternity and newborn care;
    • mental health and substance use disorder services, including behavioral health treatment;
    • prescription drugs;
    • rehabilitative and habilitative services and devices;
    • laboratory services;
    • preventive and wellness services and chronic disease management; and
    • pediatric services, including oral and vision care.

    Defending Women

    Before 2010, it was not uncommon for women to be charged much more than men for health insurance coverage or to be denied coverage altogether. Gender, it seemed, was a preexisting condition. Uninsured rates among women increased from 13% in 2001 to 20% in 2010. By 2018, that figure was down to 11%. Creating a level playing field for coverage closed the uninsured gap for women across the country. The ACA also ensured that preventive services such as mammograms and cervical screenings were covered with no cost-sharing, leading to earlier cancer detection and more successful treatments and outcomes. In addition, the law required insurers to cover breastfeeding supplies, resources and supports for new parents, and notably, it mandated that employers provide a private place -- and not a bathroom -- for purposes of pumping or breastfeeding. As a mother with a son born in 2009, I can tell you that would have come in handy for me.

    Committing to Primary Care

    The ACA created the Teaching Health Center Graduate Medical Education Program. The $230 million included in the law (for years 2011-2015) expanded primary care and dentistry residency programs in community-based settings -- many of which are located in medically underserved areas. What's more, research from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care found that residents were more likely to stay near the areas where they trained, fostering greater access to care. Sixty-five percent of residents in the THCGME program in 2018-2019 were training in family medicine, creating a needed pipeline of family physicians to vulnerable populations.

    Recently, the House voted 234-179 to pass the Patient Protection and Affordable Care Enhancement Act (H.R. 1425), which would expand the ACA's tax credits to make insurance more affordable for individuals and families, incentivize states to adopt Medicaid expansion, allow the government to negotiate prescription drug prices, and reverse the current administration's rules expanding the availability of short-term limited duration insurance plans. According to Congressional Budget Office estimates, enacting the bill would reduce the number of people who are uninsured and lower gross premiums for nongroup coverage by 8%, while reducing the deficit by more than $15 billion through 2030. Although the bill is not expected to pass in the current political environment, it is encouraging that there are efforts to improve on this framework and address unmet needs.

    It's easy to lose sight of these accomplishments over time and hard to remember a time when these protections weren't in place. We could debate endlessly the merits of the law and what it did or didn't achieve, but I hope we can agree that there are many provisions that should be heralded as completely necessary and long overdue. But the work is far from done. Unsustainable premium increases that far outpace inflation -- due in large part to skyrocketing drug costs -- continue to tax the system in ways that implore action. There is no question that many of these therapies are changing the course of modern medicine, but these burgeoning costs cannot be sustained. In addition, much of the positive forward motion to make the insurance market more consumer-friendly explicitly exempted Employee Retirement Income Security Act plans, or self-funded employer plans, creating a bifurcated system with varying levels of protections for those who have insurance coverage through their employer.

    The Supreme Court is expected to begin hearing oral arguments on the latest challenge this fall and will potentially render a decision in the spring of 2021. No matter the outcome, I suspect that the debate will rage on for years to come. I hope we can come together to build on what has worked and address the things that have not. These issues are too important for us to sit on the sidelines.

    Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.


    Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.  Read author bio »


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