One week after Republicans introduced their controversial “repeal and replace” legislation for the Affordable Care Act, the Congressional Budget Office estimated that the bill would result in 24 million fewer people being insured by 2026, while insurers and the wealthy would be nearly $600 billion richer. “In terms of insurance coverage, it’s immoral; in terms of giving money to the rich at the expense of working families, it is indecent and wrong,” House minority leader Nancy Pelosi told reporters at a press conference. It is also out of touch with what the American people have come to expect since the implementation of the Affordable Care Act, which has sent our uninsured rate to a record low of less than 9 percent. The Obama administration was clear that the objective of the ACA was to “insure everybody, to get everybody into the health system,” as Kathleen Sebelius, the former secretary of Health and Human Services, recently explained on Meet the Press. Congressional Republicans have no such goal. “We always know you’re never going to win a coverage beauty contest when it’s free market versus government mandates,” House Speaker Paul Ryan said in response to the CBO report.
Even the most vociferous opponents of the ACA have, from the start, defended some features of the law, such as the ability of parents to keep children under the age of 26 on their insurance and the ban on refusing coverage to people with preexisting conditions. Those defenders include Republican lawmakers, who incorporated both of these widely popular features in their repeal bill. But until the bill was unveiled, what was less often defended was the ACA’s role as an instrument of social justice. At its most basic, mitigating the United States’ gaping class divide on health-care access is exactly what the ACA did. And with their proposed legislation—coming up for a full House vote as soon as March 23—that is exactly what the Republicans are trying to undo.
Prior to passage of the ACA, most low-income adults could not receive Medicaid because income-eligibility limits were downright draconian in most states—well below the current federal poverty level of $11,880 a year for an individual. In a blatant gesture of discrimination, federal law excluded non-elderly, nondisabled adults without dependent children entirely from Medicaid eligibility. How sick you were, what health crisis you were facing, did not matter. If you suffered, you suffered. If you died, you died—as an estimated 20,000 to 45,000 Americans did each year because they didn’t have health insurance. That had become the American way.
The ACA began to change that. With Medicaid expansion, the Affordable Care Act went a long way toward increasing access to health care for many of America’s forgotten poor, near-poor, and disabled. The expansion made 11 million non-elderly adults with incomes up to 138 percent of the federal poverty level ($16,394 a year for an individual) newly eligible for Medicaid, with no or very-low-cost premiums, leaving them responsible only for other nominal health-care costs. It opened the door to Medicaid for adults who had no dependent children. And it expanded Medicaid eligibility for more people with disabilities. That not only made them healthier; it also protected them from lives of forced institutionalization. Medicaid is the primary payer for the cost of long-term support services that are critical to the ability of low-income people with disabilities to live, work, and be active in the community; private insurers and Medicare provide precious little support for these or related services.
The ACA also gave a financial leg up to people who earned too much to be eligible for Medicaid but still much less than would enable them to buy private insurance independently. It enabled those with incomes from 100 to 400 percent of the federal poverty level ($11,880 to $47,520 for individuals; $24,300 to $97,200 for a family of four) to buy health insurance on the public exchanges with the aid of premium tax credits, as long as they didn’t have access to a qualified plan through an employer. An estimated 85 percent of the 11 million people who bought health insurance on the state or federal marketplaces did so with the aid of tax credits that lowered their premiums. In addition, more than 6 million of the lowest-income people—those with incomes from 100 to 250 percent of the federal poverty level—also became eligible for cost-sharing reductions, which cap out-of-pocket costs like deductibles and co-pays. All told, the ACA extended health insurance to 20 million formerly uninsured low- and moderate-income people.