Discover more from Aleka Gürel
How the ACA impacts you, specifically.
It's not just about "Obamacare."
Hi, friend. It's been a little while since we've last spoken. To be honest, work has been hectic for the past few weeks and booting up my laptop on the weekends felt like more than I could bear. But then on Friday we got the news that Justice Ruth Bader Ginsburg passed away, and between the tragedy that is the loss of a great figure and the potential implications of the resulting Supreme Court vacancy, I felt the need to write again.
There are, of course, many areas of law that will be impacted by who the new justice ends up being, but the one I know most about is the pending case now called California v Texas, due to be argued before the court on November 10th. In short, the argument is that when Congress set the ACA's individual mandate penalty – better known as the fine for not having health insurance – to $0, it made the whole law unconstitutional.
I'm not a legal scholar and I won’t opine on what’s coming. (If you want the nitty gritty, you should read University of Michigan law professor Nicholas Bagley's pieces on this.) But when I’ve spoken with friends and family about this - and frankly, watched pundits talk about it on TV - there’s a worrying tendency to assume that the ACA primarily helps "other people.” Not so! If you're a US resident who's used healthcare in the past 10 years, you've probably benefited from the ACA, as have I.
So here’s a quick list of questions. In the past 10 years, have you:
1. Been covered by a parent’s health plan up to the age of 26? Congratulations, you've probably benefited from the ACA!
One of the most popular provisions of the ACA is that young adults can now, in most cases, stay on a parent's health insurance coverage until the age of 26. Before the ACA, many states wouldn’t let you stay on a parent’s insurance plan unless you were a full-time student. At the time the law was signed 25 states had laws that gave you a few extra years of coverage, but they varied broadly and often excluded young people who were married or were offered coverage through a job.
2. Had a pre-existing condition? Congratulations, you’ve probably benefited from the ACA!
Before the ACA, most states allowed individual health insurance plans (those you don’t get through an employer) to flat out reject your application for coverage if you had a pre-existing condition. Think your health is good enough that you’d be unaffected? 52 million Americans have a “declinable” pre-existing condition that would render them automatically uninsurable - things like cancer, HIV, and kidney disease, but also alcohol addiction, obesity, and pregnancy. Certain insurers also kept lists of high-risk professions that would make you ineligible for coverage, like miners, loggers, professional athletes, fire fighters, and taxi cab drivers.
Alright, but what about those of us with less severe medical conditions? You could be charged more, given a higher deductible or have coverage for a specific condition carved out of your plan for having depression, anxiety, hypertension, bone fractures, UTIs, varicose veins, hypertension, and even acne. Odds are high you’ve been diagnosed with one of these issues - I’ve had several.
What about folks who had health insurance through their employers? HIPAA has required these plans to cover pre-existing conditions since 1996. (It’s not just about privacy, y’all.) However, these plans could still impose waiting periods if you’d had a gap in coverage, meaning you might not be able to get coverage for pre-existing conditions for a certain period of time. Not great if, say, you need medication for a chronic condition.
If you’re interested in learning just how bad the situation was, read this excellent Kaiser Family Foundation analysis, from which most of the stats above are drawn.
3. Had a big medical bill? Congratulations, you’ve probably benefited from the ACA!
Before the ACA, 59% of workers had a lifetime limit on their health plan, meaning that once you incurred a certain amount of medical spending (say, $1 million dollars) your plan wouldn’t pay for anything else. That might sound like a lot of money, but a condition like hemophilia, a NICU stay for a baby with complex medical needs, or a long hospitalization with coronavirus can eat through that pretty quickly. Thanks to the ACA, employer and individual health plans are no longer allowed to have these limits.
How about out-of-pocket spending? Before the ACA, 1 out of 5 employer plans lacked an “out of pocket maximum” – a provision that caps the amount of money you spend for your care, not including premiums, every year. Many that did have an OOPM didn’t count prescription drug costs towards the limit, a pretty important exclusion given that prescription drug spending accounts for 21% of health spending by employer plans. The ACA mandates a limit on most plans of at most $8,150 for a single person and more for a family– still a lot of money, to be sure, but preferable to the catastrophic debt that could otherwise occur.
4. Used a preventive care service? Congratulations, you’ve probably benefited from the ACA!
Another critical part of the ACA is the requirement that most health plans must cover dozens of preventive care services at no cost, even if you haven’t met your deductible yet. That includes things like cancer screenings, blood pressure screenings, many immunizations (including the HPV vaccine and your annual flu shot.)
Birth control is also on that list, and allowing folks to access it at no cost has had an enormous impact. Putting most methods of birth control (notably, condoms and vasectomies are excluded) on equal footing in terms of cost is a big win — now people have the freedom to pick the method that works best for them, not the one that works best for their wallet. Practically speaking, the amount that folks spend on birth control has also plummeted - here’s one striking graph:
On a more immediately pressing note, having vaccinations covered at no cost is a really important thing during, say, a global pandemic.
5. Freelanced? Started a business? Or had a gap in coverage between jobs, looked at your COBRA notice, and thought, “holy moly, that’s expensive”? The ACA probably gave you far better options for coverage.
Before the ACA, your main options for keeping your health coverage after leaving a job were to join a spouse’s plan, brave the individual market for a plan with big gaps in coverage, or continue your employer plan through COBRA.
COBRA was, and is, wildly expensive: you pay 102% of what your employer coverage actually costs, including the part your employer used to cover (usually north of 70%.) That brings that average cost of COBRA to ~$600 for a single individual and a lot more for a family – unaffordable for most people. Plus, it typically only lasts 18 months.
The ACA created two major pathways to coverage if you don’t get a plan through work:
You can buy a plan through the ACA Marketplace (often referred to as “Obamacare”) and know that it’s going to cover your pre-existing conditions and essential health benefits, like maternity care and prescription drugs. You’ll probably also qualify for a subsidy that brings the cost of that plan down to something much more affordable than COBRA.
In 38 states + DC, if you’re even temporarily making less than ~$1,400 a month (~$3,000 for a family of 4) you can get free or low-cost coverage through Medicaid. This was supposed to be the case in all states, but the Supreme Court said no. Happily, the list expands every year - Missouri and Oklahoma just passed Medicaid expansion by ballot initiative.
Given that getting people access to these types of coverage is what I do for a living, I could go on for hours about how these two pathways have helped millions and saved thousands of lives. But if you don’t see yourself as the “target audience” for these programs, I’d respectfully disagree. What if you quit your job? Get laid off? Get divorced? Strike out on your own? Found a startup?
No, the ACA isn’t perfect - the coverage available is still too expensive for many, and many areas of our health system are still fundamentally broken. (The Medicaid Gap, the family glitch, surprise billing, to name a few.) But it’s a critical stepping stone to something better, and if it disappears, millions of people will suffer. You should care about that because you care about your fellow Americans. But the stakes are more than likely personal, too.
We’ll be back to our regularly scheduled programming on recipes and reading next week, I promise! (As a brief update, I’m currently escaping real life through the Six of Crows duology and continuing to eat absurd quantities of pad ka prao.) But in the meantime, here’s your regular reminder that if you have questions about your health insurance or need help finding coverage, I’m always here to help. You can find me on Twitter or Instagram.