JAMA Forum: The Human Consequences of Repealing the Affordable Care Act

Dave A. Chokshi, MD, MSc (Image: NYU Langone Medical Center)

Dave A. Chokshi, MD, MSc (Image: NYU Langone Medical Center)

Within the maelstrom that is US politics today, some may lose sight of the tangible, human consequences of repealing the Affordable Care Act (ACA). Is it 22 million or 32 million who would lose coverage if the ACA were repealed without a commensurate replacement plan? The abstraction of large numbers obscures the pain that would ensue, such as interruption in care for the cancer patient who has just started treatment or regression for the patient whose paralyzing anxiety had become manageable.

More than 4 million children would lose health insurance if the ACA is repealed via budget reconciliation (due to a combination of effects on Medicaid eligibility, the Children’s Health Insurance Program, and private nongroup coverage); almost 1 million of these are younger than 5 years. President-elect Donald Trump’s nebulous promise of “insurance for everybody” notwithstanding, even if Congress passes a replacement plan, it may fall short for people who need health care. For example, both House Speaker Paul Ryan (R, Wisconsin) and the nominee for Secretary of Health and Human Services, Rep Tom Price (R, Georgia) have previously proposed a plan that would eliminate the essential health benefits mandated by the ACA, such as chronic disease treatment and rehabilitation services. Cutting the ACA’s essential health benefits may lower the price of some plans targeting young and healthy people, but it would raise costs for sicker, often older, patients.

Poor and working-class Americans are most likely to suffer. Largely due to the ACA, the proportion of uninsured nonelderly veterans decreased from 11.9% in 2013 to 6.8% in 2015. Rolling back the ACA’s expansion of Medicaid leaves in the lurch 15 million people who have been newly covered since 2014. If Medicaid were funded below pre-ACA levels, as in some Medicaid block-grant proposals, even more people would become uninsured. Support for long-term care for people with disabilities, a key function of Medicaid, would be eroded.

Health coverage brings not just financial peace of mind, but real gains in access to health care. For instance, states with greater gains in coverage between 2013 and 2015 also experienced larger declines in the share of individuals who did not see a physician because of cost. In Kentucky and Arkansas, Medicaid expansion was associated with significant increases in preventive care use, reductions in emergency department use, and improved self-reported health. In Michigan, Medicaid expansion resulted in several economic benefits including thousands of additional jobs and an improved state budget outlook. These broad advantages may be why 16 Republican governors, as well as 15 Democratic governors, have elected to expand Medicaid. Their voices will be particularly important in the impending debate.

Cuts to health coverage will not occur in a vacuum. Even as the number of uninsured people increases, support for uncompensated care in an ACA replacement plan is unlikely to keep pace. A report, commissioned by the Federation of American Hospitals and the American Hospital Association, estimates a financial loss of $165.8 billion between 2018­ and 2026 if Congress were to pass an ACA repeal bill similar to one vetoed by President Obama in January 2016. In reality, the responsibility of caring for uninsured patients would not be borne equally by all hospitals. Instead, safety-net health systems with already slim or negative operating margins are more likely to serve as refuges, placing additional pressure on local and state budgets.

More important, the same people whose coverage may be affected will simultaneously bear the brunt of other dislocations affecting health. Speaker Ryan has signaled his intent to cut food stamp benefits, even as 12.7% of all American households remain food insecure. Because growing evidence supports the notion that solutions to issues like education quality and affordable housing are at least as important to health as health care, stewards of public health must monitor the effects of the new administration’s proposed policies in these domains.

Another ACA provision likely to be included in repeal without replacement would eliminate an important stream of funding for the Centers for Disease Control and Prevention (CDC). This would jeopardize the CDC’s ability to respond to urgent public health threats, such as the opioid crisis affecting millions of Americans. The current CDC Director, Tom Frieden, MD, estimates a toll of more than 10 000 additional deaths if this funding were not preserved.

Only 20% of Americans want Congress to repeal the law immediately and work out the details of a replacement plan later. It is clear that a number of Republican senators prefer a path forward that pairs repeal with concomitant replacement, a more politically challenging prospect. Still, a broad-based coalition would be needed to retain the ACA (or ensure a comparable replacement). Moderate and conservative organizations, such as the Christian religious groups that filed a Supreme Court amicus brief supporting Medicaid expansion, would need to weigh in again. Health professionals are also an important segment of any such coalition; in recent weeks, the American College of Physicians, the American Public Health Association, and the American Hospital Association have all expressed concerns about repeal plans. The American Medical Association has clarified its commitment to insurance for all Americans.

Health professionals may have a particular role in calling attention to the stories of individuals affected by the debate playing out in Washington. For example, Rebekah Gee, MD, the health secretary of Louisiana, has pointed to the thousands of people who have been able to access colorectal cancer screening as a result of Medicaid expansion in that state. Media sites like Vox, foundations such as the Commonwealth Fund, and political action groups like the Center for American Progress have all begun cataloguing patients’ stories. To shift the legislative winds, those stories would have to reach Congressional Republicans, starting with those who have begun to express reluctance about repealing the ACA before a replacement plan has been vetted.

Physicians and other clinicians bear witness to how abstract policy “hits the ground” and alters the trajectories of people and communities. In these extraordinary times, sharing those observations—with our neighbors, our colleagues, and our elected representatives—can help make an entrenched, charged, and momentous conversation a more humanistic one.

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About the author: Dave A. Chokshi, MD, MSc, is the Chief Population Health Officer of OneCity Health and Senior Assistant Vice President at New York City Health + Hospitals—the largest municipal health system in the United States. He is a primary care internist at Bellevue Hospital and Clinical Assistant Professor of Population Health and Medicine at the New York University School of Medicine. He tweets at @davechokshi. The views expressed in this post do not necessarily reflect the position of NYC Health + Hospitals nor NYU.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Categories: Caring for the Uninsured and Underinsured, Health Policy, The JAMA Forum

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