Let’s celebrate the Affordable Care Act anniversary, and finish the job of assuring healthcare for all

In the long struggle to win quality, affordable, equitable healthcare for everyone in our nation, there have been two large expansions of health insurance coverage beyond the private, employer-based insurance system established after the Second World War as a way to provide insurance coverage to veterans returning from their military service: the establishment of Medicaid and Medicare in 1965, and the passage of the Affordable Care Act (ACA) and creation of the healthcare marketplaces in 2010.

At the time the private employer-based insurance system was created, it was not intended to serve as anything other than a temporary measure to meet veterans’ healthcare needs. Establishing public health insurance programs in 1965 and 2010 required a pitched political battle largely centered on whether the government should create a healthcare safety net for more Americans. That role of government in guaranteeing healthcare remains contested today–we can see it in the current Congressional debate about spending cuts to Medicare and Medicaid, the nation’s most popular health programs.

The action that lawmakers took in 1965 and again in 2010 to leverage the power of government to expand access to affordable health coverage resulted in tens of millions of people—seniors, the working poor, persons living with disabilities, those between jobs, and those arbitrarily or systematically denied private coverage–getting health care for the first time. These were huge steps forward in addressing a long legacy of racial, gender and class discrimination in healthcare coverage that has long perpetuated inequity and worse health outcomes for some groups over others. These interventions worked but there remains a lot of work left to do.

We look forward to further progress when Medicaid expansion is finally adopted in North Carolina and 600,000 more persons become eligible for coverage, thanks to the Affordable Care Act. As we mark the thirteenth anniversary of its passage on March 23rd it’s valuable to examine the law’s most recent impact on extending quality, affordable healthcare for more people, and to consider other improvements in access and affordability that have resulted in historic progress but still not finished the job of guaranteeing quality, affordable and equitable care to all.

The Kaiser Family Foundation estimated that nearly 27 million people lost employer-sponsored health insurance in March and April of 2020 because of the COVID pandemic. Thanks to the ACA, 4 out of 5 of those people were eligible for coverage through the ACA health insurance exchanges or Medicaid. Thanks to Covid-era policies such as the American Rescue Plan, the number of uninsured people in America fell to unprecedented lows last year. The Inflation Reduction Act (IRA) passed last year extended some of these policies through 2025, particularly the enhanced tax credit that make healthcare coverage more affordable for people at every income level. For the first time, upper middle income families who were previously priced out of coverage became eligible for tax credits to buy coverage. The premium tax credits cap the cost of healthcare at 8.5% of income. In addition, the Inflation Reduction Act has lowered drug prices for Medicare enrollees and held drug corporations accountable for raising prescription prices faster than inflation. It has also lowered costs and expanded private coverage to many people by saving people in North Carolina an average of $760; expanding coverage to about 135,000 who would otherwise be uninsured; and providing affordable coverage to 106,000 small businesses that make up 23% of ACA enrollees in the state.

Affordable healthcare in ACA marketplaces will continue to be critically important as the pandemic subsides and millions of people find themselves with expired coverage. The Public Health Emergency (PHE) declaration, which helped expand coverage and care in unprecedented ways to respond to the COVID pandemic, will end on May 11th. With it will expire critical public health measures, like streamlined enrollment, presumptive eligibility and continuous coverage in Medicaid that have resulted in record Medicaid enrollment.

Medicaid enrollment grew by 20 million people between 2020 and 2022, to over 90 million. KFF estimates that between 5.3 million and 14.2 million people will lose Medicaid coverage during the 12-month “unwinding” period following the end of the PHE, as Medicaid contracts back to pre-COVID levels. Some estimates are even higher.

Exactly how many people lose coverage will depend on how states manage the process, whether states commit to robust outreach for new enrollment and whether they leverage waivers to help reduce turnover in the program. Some people who lose Medicaid coverage will be newly eligible for ACA coverage, but past experience shows that outreach is required to get these eligible people covered.

Medicaid and the ACA could be further endangered by GOP calls to cut spending in order to reduce the federal deficit in the upcoming Congressional budget battle. For a decade, Republicans have tried to repeal, weaken, stall and slash these programs, frequently proposing cuts in their budget proposals. This year, House Republicans likewise are insisting on cuts as a trade for lifting the debt-ceiling limit, which would result in widespread economic harm if not addressed.

Although Republicans have so far refused to divulge which specific healthcare cuts they will support, past experience shows that Medicaid is a likely target. Both Medicaid and the ACA are targeted in the Republican Study Committee Budget that the vast majority of GOP House Members support. Cutting Medicaid and the ACA would not only take coverage and consumer protections from millions, but it would make mental health and substance abuse treatment harder to access, force rural clinics and hospitals to shut down and extend waiting lists for seniors and people with disabilities seeking home based care.

President Biden wants to go in a different direction on healthcare than the Republicans. The budget blueprint he proposed in early March would invest more in Medicaid and ACA coverage, including expanded funding for home and community based coverage, mental health services, lower drug prices and permanent enhanced premium tax credits that save an average person  $800 per year.

The President’s plan lowers healthcare costs and reduces the deficit not by cutting coverage or benefits, but by tackling corporate price gouging and raising taxes on the wealthiest Americans who have persistently dodged paying what they owe. The proposal would create a new tax on millionaires and billionaires, reverse the Trump tax breaks on rich corporations and close special interest loopholes that enable the super rich to get away with paying lower tax rates than middle class workers. The money generated by making the rich and corporations pay their fair share of taxes would be invested to lower costs and expand coverage for people who need healthcare.

For those of us who want more healthcare access and equity rather than less, we know which side we’re on as this battle plays out. It’s a long march to the healthcare justice so many are fighting for. Let’s make sure in 2023 that we keep moving forward to a better future, not backwards to an unjust and unworkable past.

Naomi Randolph-Hwesuhunu and Pat McCoy are Co-Executive Directors of Action NC.