- The Trump administration recently argued before the Supreme Court in favor of repealing the entirely of the Affordable Care Act, also known as Obamacare.
- This would remove an estimated 20 million people off their health coverage, which is an especially dangerous move considering that the country is in the midst of a pandemic and millions of people are losing their jobs.
- Aviva Aron-Dine is the Vice President for Health Policy at the Center on Budget and Policy Priorities.
- This is an opinion column. The thoughts expressed are those of the author.
- Visit Business Insider's homepage for more stories.
Late in the evening of June 25, the Trump administration filed a brief with the Supreme Court, arguing that "the entire Affordable Care Act must fall." A few days later, the President himself urged the court to overturn the decade-old healthcare law, a move which would terminate health coverage for millions.
Trump claimed his administration would replace the ACA, colloquially known as Obamacare, with a "better" alternative and insisted that he will "almost protect" people with pre-existing conditions.
In reality, the lawsuit is just another means to the same end the administration has pursued since inauguration: ACA repeal with no meaningful replacement.
Even before the pandemic and downturn, repealing the ACA was projected to cause 20 million Americans to lose their coverage. And millions more could be charged more or denied coverage altogether because they have a pre-existing condition or would lose other important protections.
Now, the stakes are even higher, since millions more people will likely turn to ACA programs for coverage as a result of the COVID-19 recession, which has caused unemployment to skyrocket. While Trump's push to completely repeal the ACA was always cruel, the lawsuit is even more dangerous in the midst of a pandemic and a deep recession.
The very real threat to the ACA
First, some background on the lawsuit. The administration has joined 18 state attorneys general in arguing that Congress rendered the entire ACA unconstitutional when it repealed the law's individual mandate penalty — the law's financial penalty for going without health coverage — as part of the GOP-supported tax reform law that was passed in 2017.
Legal experts, including prominent conservatives and Republican attorneys general from two other states, have called that claim absurd. So have two Republican senators who voted to repeal the mandate penalty. When the Justice Department first announced its position, three senior career attorneys withdrew from the case, one of whom resigned from the department.
Nonetheless, two judges on the Fifth Circuit Court of Appeals sided with the administration and the states pushing for repeal on part of their argument, which has led to the Supreme Court hearing the case.
Compounding a Crisis
The Supreme Court will likely render its decision in the first half of 2021. At that point the unemployment rate is still expected to hover around 10%and there is a possibility that the US could still be grappling with another wave of coronavirus infections .
With a 10%unemployment rate, as many as 2 million more people might be enrolled in Medicaid expansion than without the recession, and as many as several million more might be enrolled in the marketplaces, Urban Institute estimates suggest. Since these structures were set up by the ACA, striking down the programs could leave these people without health coverage.
ACA coverage programs have improved access to care, financial security, and health outcomes, research shows. There is strong evidence that both coverage through the ACA marketplaces as well as the option for states to expand their Medicaid programs save lives. Reversing these coverage gains would likely worsen all of these outcomes, and the adverse effects would be even greater now, with more people depending on the ACA during the recession.
In addition, the ACA provision allowing young adults to stay on their parents' health plans until they turn 26 also will likely prove more important during the recession. A quarter of young workers lost their jobs between February and May, nearly double the share among any other age group.
The ACA also significantly narrowed racial disparities in health coverage, and the lawsuit would widen them. Based on pre-crisis estimates, repeal would cause nearly 1 in 10 non-elderly Black people, and 1 in 10 non-elderly Hispanic people, to lose their health insurance, compared to about 1 in 16 white people.
Striking down the ACA would also end crucial protections for tens of millions of people who would remain insured. For example, it would eliminate the ACA's prohibitions on denying coverage or charging higher premiums to people with pre-existing conditions; allow insurers to go back to putting annual and lifetime limits on coverage; and end the requirement that insurers cover preventive services, including vaccines, without cost sharing.
While so many Americans would lose so much from an ACA repeal, those at the top would gain. Repeal would cut taxes sharply for the highest-income Americans and certain corporations. The highest-income 0.1%households — with annual incomes of over $3 million — would receive tax cuts averaging about $198,000 per year, the Tax Policy Center estimates.
Tax cuts for households with incomes over $200,000 would cost the federal government about $30 billion in 2020. That's over one-third of the federal cost of the ACA's Medicaid expansion to low-income adults, meaning that it could pay for health coverage for over 4 million people.
In effect, the Administration and the state attorneys general are seeking a massive transfer of resources from low- and moderate-income people to those at the top.
Trump's plan should come as no surprise
Trump's vision for America's healthcare system is no surprise, since his administration has consistently pursued – through litigation, legislation, and executive actions –ACA repeal without proposing a meaningful replacement.
During the 2017 congressional debate over ACA repeal, the President voiced strong support for four separate repeal bills that Congress ultimately rejected, each of which would have caused at least 20 million people to lose coverage. The budgets he proposed in 2018 and 2019 urged Congress to adopt one of these proposals and then proposed more health care cuts, while this year's budget calls for $1 trillion in unspecified cuts to Medicaid and the ACA's premium tax credits.
The President's agenda is equally clear when it comes to protections for people with pre-existing conditions. He's repeatedly urged Congress to let states waive the ACA's core protections, an approach that health plans, physicians, hospitals, experts, and independent fact checkers all concluded would leave people in most of the country unprotected, just as they were before the ACA.
What's more, the President isn't waiting to see if the courts strike down the law. He's using his executive authority to encourage states to take coverage away from many people covered through Medicaid expansion, to cut outreach and financial assistance for ACA plans, and to promote plans that aren't subject to the ACA's pre-existing conditions protections.
Trump has also refused to open up marketplace coverage to more people losing their jobs and income during the recession, despite being urged to do so by governors, health plans, and consumer advocates. And he's repeatedly pledged to pursue ACA repeal legislation again in 2021 if he's reelected and Republicans regain control of both houses of Congress.
The Administration's efforts to repeal the ACA have always threatened health and financial hardship for millions. Doubling down on them in a time of crisis would only add to the devastating results.
Aviva Aron-Dine is the Vice President for Health Policy at the Center on Budget and Policy Priorities. Prior to rejoining the Center in 2017, Aron-Dine served as a Senior Counselor to the Secretary at the Department of Health and Human Services, with responsibility for Affordable Care Act implementation and for Medicaid, Medicare, and delivery system reform policy.
This is an opinion column. The thoughts expressed are those of the author(s).
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