Photo by LaDawna Howard 
When Inga Haugen set out to farm two hundred and thirty acres of rolling grass in Canton, Minnesota, she didn’t expect it to be easy. There was the fact that she was a 26-year-old woman in an industry run by graying men. There were the fifty pigs, several cows and nearly 200 chickens to buy and take care of. There was an agreement to be ironed out with her parents, who owned the land, and a tight market for the meat she hoped to sell.
But the obstacle that infuriated her was one she didn’t see coming: the extraordinary cost of obtaining health insurance for herself.
“I don’t gamble,” Haugen says, “except that I farm. You are gambling when you work with critters, with machinery.” As a small-business owner in one of the most dangerous industries in the country, Haugen needed insurance, and her options were dismal. She could reckon with a steer, but insurers deemed Haugen high-risk and overweight, which counted as a pre-existing condition, and sent her premium soaring. “It made me so angry,” she recalls. “Of all the barriers I faced trying to move home to farm, that was the one that rankled the most.” Every year, Haugen paid a fifth of her income to her insurer. She made a go of it for a few years, but stepped back in 2011 to let her two brothers try their luck on the land.
Thor Haugen, who is 23, has an advantage that his older sister did not: he can stay on the family insurance plan while he finds his footing on the farm. Some 2.5 million young Americans have recently gained coverage this way, thanks to the Affordable Care Act. The requirement that private insurers cover dependents until they turn 26 was one of the first of the law’s provisions to take effect, and the first to impact young adults in particular. By the time the full provisions of the ACA roll out in 2014, another 12 million young adults will gain coverage through an expansion of eligibility standards for Medicaid and through the creation of insurance exchanges. The law also expands access to care for young adults with insurance. Young women will no longer pay higher premiums simply because they are women, and providers will be required to cover preventive, primary and maternal care, including birth control, with no cost-sharing. Lifetime benefit caps on student health plans will be banned, along with discrimination based on pre-existing conditions.
In other words, the ACA could profoundly improve the lives of the 15 million uninsured Americans between the ages of 19 and 29. But only if it survives. The Supreme Court will rule on the constitutionality of the law before the end of this month. The young people who stand to gain from the ACA represent a political constituency that was crucial in 2008—as well as the segment of the population most likely to be uninsured. Will Obamacare get them to the polls?
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In April, Supreme Court Justice Samuel Alito suggested that the stakes are low for the millions of uninsured young Americans. “When [young adults] think they have a substantial risk of incurring high medical bills,” he said from the bench, “they’ll buy insurance, like the rest of us.” The trouble, as Inga Haugen discovered, is that many can’t afford it even if they want it. And while that population may be generally healthy, so-called young invincibles are the least likely to be insured or to be able to pay out of pocket for care when they do need it. Abigail English, director of the Center for Adolescent Health and the Law, called the idea that young adults don’t need or want insurance “completely nuts.” Young Americans “face many kinds of transitional issues,” she says, meaning they fall into gaps in coverage as they navigate from family and school insurance plans to employer-sponsored plans—additionally difficult in a grim job market in which employers are offering fewer benefits. Meanwhile, the ranks of young adults with chronic conditions like diabetes and asthma are growing, and the population is uniquely at risk for traumatic accidents.
One afternoon, Talon Hoke grabbed his skateboard and went out for a ride in Hood River, Oregon. Coming down a steep hill at nearly thirty-five miles an hour, he fell, hitting his head as he tumbled down the road. At 19 years old, he spent a month and a half in a coma, and a total of five months in the hospital, where he contracted three rounds of staph pneumonia and where surgeons accidentally severed his thoracic duct. At the time Hoke was insured through his family plan, but the coverage was limited, and he came away with $800,000 in medical debt. At 20, he declared bankruptcy.
“I was a victim, and I am a victim, of really unaffordable healthcare,” Hoke says. Though Hoke now has insurance, the coverage is not sufficient to make going to the doctor affordable; he says that if he were seriously injured or sick again, he would go to the emergency room. The costs would be passed on to taxpayers. In 2009, the Commonwealth Fund found that more than three-quarters of young adults put off needed care because of costs. Hoke’s situation illustrates Justice Anthony Kennedy’s argument that “the young person who is uninsured [or underinsured] is uniquely proximately very close to affecting the rates of insurance and the costs of providing medical care in a way that is not true in other industries.”
Arijit Guha, a graduate student at Arizona State University who grew up in a “comfortable, upper-middle-class home,” had long nurtured “an interest in progressive politics and healthcare.” Those issues “had always been abstract,” until early 2011, when he returned from his honeymoon in India with what he thought was a stomach parasite. A doctor discovered a malignant growth in his colon. Surgery revealed tumors strewn throughout his abdominal cavity.
Less than a year of aggressive treatment put Guha over the lifetime cap on his student health insurance plan. His medical bills average $25,000 a month, more than half of what he and his wife earn in a year. Guha says the state of Arizona made matters worse when the state “decided it was more important to cut [healthcare] and distribute a few tax breaks to rich people than have a decent social safety net in place.” Narrowly defined criteria left him ineligible for Medicaid, and in 2011 the austerity ax lopped off a state program for people like him whose medical costs put them at risk for bankruptcy.
The Affordable Care Act could save Guha from the financial ruin of fighting for his life. In 2014, insurers will no longer be able to deny him coverage because of his illness, and lifetime caps on student health plans will be banned. “I am clearly not the sort of case that insurers are excited to take on,” he says. “But that’s the entire reason we have to have the individual mandate.” In the meantime, Guha can enroll in a transitional insurance program, but not until he’s been uninsured for six months. He is conscious of the fact that the law might vanish before then. “If the Supreme Court were to get rid of the act, or if Congress repeals the act, suddenly it would not be a six-month period of being uninsured but quite [a lot] longer,” he says. For now, as Guha undergoes chemotherapy and further surgery, he is fundraising. A strong network of friends have helped him develop a successful campaign based around a website called poopstrong.org . “Most people in my situation are not nearly as lucky,” he says.
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The ACA’s most hotly debated provisions—those related to sex—may also do the most to win support from young adults. The law will transform access to sexual and reproductive care, in part by requiring that all insurance plans provide coverage for contraception without a co-pay. Nineteen-year-old Jessika Parry is a student at Boston College, where that aspect of the law has been particularly controversial. The Jesuit college has objected to expanding access to contraceptives in student and employee insurance plans, because doing so would, according to a letter sent to the Secretary of Health and Human Services that BC administrators endorsed, help “our students to act contrary to Catholic teaching and belief.” Parry began taking oral contraceptives for health reasons when she was 15, before she was sexually active. At BC, she was “surprised” to find that the college “didn’t provide the kind of resources I assumed that it would for its students, such as contraception, or even condoms.” She has obtained coverage for her medication through her parents’ insurance plan, but knows other students who don’t have that option. According to Parry, the college’s religiously guided health policy is at odds with the fact that it “doesn’t accept its students based on any religion or belief system.” Because BC prides itself on its diversity, she said, “I find it very interesting that in this issue, which definitely implicates that diversity, they’re not really taking that into account.” Parry said she knows students who make the choice to be sexually active even without access to birth control. “If colleges choose not to offer contraception, it does put their students at a little bit of a risk," she says.
The ACA will also require all insurers to cover a broad range of other primary, preventive and maternity care services that until now have been out of reach financially for many young women. Sarah Audelo, a 26-year-old Texas native who now works for the DC-based Advocates for Youth, says that the expanded provisions are particularly important as legislative attacks on organizations that provide free or low-cost services, like Planned Parenthood, intensify. In towns like Mission, Texas, where Audelo said one shuttered clinic has been turned into a tire shop, the impact has been “heartbreaking.”
Audelo says that “young people are very conscious of sexual health issues,” and she speculates that young voters might rally around healthcare now that now that it is front and center in the political arena. It isn’t only women who “are upset about attacks on birth control coverage,” she says. It’s also “young men who are having conversations with their partners, [who] are agreeing that they are not ready to have a child yet,” and those interested in services like STD testing. But at BC, students have not united around the ACA as much as Jessika Parry thinks they should. “I just don’t think that BC students realize how much it impacts them directly,” she says. Audelo notes that the law “can be a little confusing for people” because of its complexity and the fact that it is unrolling over four years. The ACA hadn’t “been a game changer” politically for her peers, says Inga Haugen, because “the individual portions of it have been difficult to understand for some folks.”
Polls suggest that the ACA has an image problem with young adults. A survey of young adults between the ages of 18 and 29 found that more than half disapprove of the way the president is handling healthcare— yet only 23 percent objected to the idea that health insurance is a basic right that the government should provide to those who cannot afford it themselves. That gap suggests that the ACA needs better PR—and that Obama’s bid for re-election would benefit from it. Organizations like Advocates for Youth, the Commonwealth Fund, Young Invincibles and HERvotes are working to educate young voters on the specifics of healthcare reform, and to get the message back to policymakers that young people want access to care. But spreading information might not do enough to reach Thor Haugen’s peers, who, he says, support or oppose the law depending on whether they are Republican or Democrat. Even so, young adults are the age group most likely to approve of the ACA, and activism around the law could re-energize a Democratic youth base that seems unsure whether Obama is worth showing up to the polls for.
There are even misgivings about the ACA among young Americans who voted for the president in 2008. Talon Hoke and Arijit Guha said they would have preferred a single-payer plan akin to Medicaid or the VA system to the individual mandate paired with insurance exchanges. The ACA also does little for the nearly 2 million undocumented young adults living, working and studying in America without insurance. Still, Hoke plans to vote for Obama again. “What [President Obama] is trying to do is help Americans get better, more affordable healthcare,” he says. “That’s an awesome idea. It needs to happen.” His girlfriend has already benefitted; at 24, she was able to get back on her father’s health insurance plan, fill prescriptions, see an optometrist and get new glasses.
The state of the economy trumps all other issues for young adults, but healthcare could factor into concerns about employment and finances. (In a recent poll, young adults chose healthcare as their second-most-pressing issue, ahead of national security.) Ensuring access to healthcare for young people can drive entrepreneurship, enable young people to work in the public interest or, as for Haugen, join a profession that desperately needs new blood. “Folks need to be able go and do what they are passionate about,” says Haugen, “especially if what they are passionate about is feeding our nation. Farming is hard enough.” But rather than trumpet the far-reaching implications of the ACA, the White House has focused instead on the law’s measurable successes to this point, such as the 2.5 million young adults newly insured through a family plan. In response to questions about why the Obama administrated hasn’t touted its signature domestic accomplishment more aggressively, press secretary Jay Carney said  that implementing the law alone was a “full plate.” In March, the Obama campaign launched an effort to rally women around the healthcare law, but while the law’s future is in doubt, it isn’t clear whether the campaign will assign the ACA a larger role.
The ACA raises questions about which Americans deserve care and how it should be paid for. Young adults interviewed for this article said they support the ACA not only because they have an individual stake in its survival but also because the law expands, if imperfectly, a crucial aspect of the social safety net that has until now been denied to swaths of American citizens. As Arijit Guha put it, “A sane, just, equitable society is one where we pitch in for one another when someone is needy.” He says that lack of insurance reinforces economic inequality, because “the people that don’t have access [to care] are the ones at the bottom of the socioeconomic ladder to begin with.” Research supports his argument: lower-income young adults are more likely than others to be both uninsured and sick. While they may struggle to pay for insurance out of pocket, the young adults I spoke to do want to invest in the nation’s health with their tax dollars. “For people to kick in their fair share seems appropriate, for something that everybody is going to use,” Inga Haugen explains. Says Hoke, “I hear about cuts in the education and healthcare system, and I think, what the hell are you guys spending the money on?” The number of young adults concerned about economic inequality has risen dramatically in the last year, as they find themselves on the descending end of the wealth gap see-saw. Even if the ACA is an insufficient political motivator on its own, it could help to galvanize young voters if, like Guha, Haugen and Hoke, they see it as part of the national debate about inequality, fairness and the worth of social services.
Back in Canton, Thor Haugen said that he will vote in the fall even though he doesn’t consider himself to be political. “I don’t want to see [the ACA] get repealed or cut back,” he said. If it is struck down by the Supreme Court, Thor won’t buy insurance; not because he doesn’t want it but because he couldn’t afford it, especially while he pays off his student loans. “Something is wrong,” he says, of a system in which millions of Americans forego the care they need because they don’t have enough money. The stakes are high for Thor; so too for the health of the body politic.