By Suzanne Wikle

Ten years after Congress passed the Affordable Care Act (ACA), it is more popular than ever—and still under threat. This week the Supreme Court heard a challenge to the ACA brought by 20 Republican state attorneys general and supported by the Trump Administration. It could strike down the law in part or in its entirety. If the ACA were to be struck down, it’s arguable that everyone will be affected. The return of lifetime limits on coverage and insurance companies’ refusal to cover pre-existing conditions are two big ones – including for people with insurance through their employer – and have gotten the most attention. However, people of color, people with low incomes, and those without insurance through a job stand to lose the most. Here are some of the other key provisions at risk with the Supreme Court case:

• Medicaid expansion has provided insurance to more than 14 million people with low incomes who live in one of the 38 states and D.C. that chose to expand Medicaid. A decision to strike down the ACA would effectively make those 14 million uninsured. Beyond harming the physical and mental wellbeing of people losing insurance, a repeal would create ripple effects. These include people not being able to remain in the workforce if they can’t get medical care, an increase in medical debt and bankruptcies, and greater uncompensated care for hospitals, leading to more hospitals closing.

Medicaid expansion has also reduced racial disparities in health insurance rates and health outcomes–progress that will likely be reversed if the ACA were repealed. Disparities in infant mortality have begun to close, but the ACA is critical to continuing progress in closing the gap.

• For persons involved with the justice system, Medicaid expansion has provided – for the first time – a way to connect to health insurance when they leave incarceration. Having insurance allows people to access physical and mental health care and prescriptions. Without the ACA, this support for people leaving incarceration will disappear.
• For people working multiple part-time jobs to make ends meet, those in the gig economy, or those employed by small businesses not required to provide health insurance, the ACA offers affordable care through Medicaid expansion or tax credits on the marketplace. This is also true for people who want to be working full time but can’t get the hours to do so—and people involuntarily working part time are more likely to be Black or Latinx. Without these options, even more people will become uninsured.

In 2020, 7.2 million individuals who enrolled in health insurance through healthcare.gov (87 percent) qualified for a tax credit to defray their premium. On average, tax credits covered all but $89/month of the premium. Some 71 percent of those getting tax credits had income between 100 percent and 250 percent of the federal poverty line, meaning they also received cost-sharing reductions to decrease their deductible and other out-of-pocket expenses.

Without the ACA, all the tax credits and cost-sharing reductions would be eliminated. The marketplace may be gone also. Millions of people who use these systems now will lose their insurance.

• Youth and young adults stand to lose a lot without the ACA. The rate of young adults without health insurance has decreased by half since 2010 thanks to Medicaid expansion, the ACA provision allowing young adults up to age 26 to stay on their parents’ insurance, and the creation of the marketplace with tax credits Youth and young adults (ages 18-34) account for 25 percent of people who enroll in health insurance through healthcare.gov. The ACA also provided Medicaid to former foster youth up to age 26. Without the ACA, we can expect a sharp increase in the number of youth and young adults without health insurance.
• College students, especially students of color, benefitted from the ACA and stand to lose if the law is overturned. Between 2010 and 2018, health insurance coverage among college students increased by 10 percentage points. This increase includes higher enrollment in Medicaid and more young adults being insured through their parents’ plans. The ACA has cut approximately in half the disparities in health insurance enrollment between white and Black or Latinx students.
• Children will also lose if the ACA is overturned. Pediatric coverage (including dental and vision) is part of the ACA’s essential health benefits package, and more children have health insurance now than before the ACA (although we have seen recent backsliding in those gains). ACA benefits for adults – increased coverage, fewer bankruptcies, and improved overall health – also create less-stressful home situations. All of this is at risk with the latest Supreme Court hearing.

Everyone, regardless of their economic status, will likely lose the pre-existing condition provision. They’ll also lose the provisions that mandate behavioral health care (including outpatient care); condemn discrimination by language, gender, or sexual identity; and require coverage of preventive services (annual check-ups, pediatric vaccines, flu shots, birth control, etc.).

Simply put, there are no winners if the ACA goes away. Everyone loses, but people with low incomes, variable job schedules, our youth and young adults, and children will experience tremendous harm. The ACA is much more than pre-existing conditions, and if the worst happens when the Supreme Court ruled next spring, Congress must act to address all the holes the ACA would leave behind.