APHA's Public Policy Analyst discusses why the ACA is critical to our health. Photo courtesy of Jason Coates.

APHA’s Public Policy Analyst Jason Coates discusses why the ACA is critical to our health. Photo courtesy of Jason Coates.

Earlier this month, the House and Senate passed a fiscal year 2017 budget resolution that allows Congress to begin the process of attempting to repeal the Affordable Care Act — a historic public health law through which twenty million people have gained health insurance coverage. We spoke with APHA’s Public Health Policy Analyst Jason Coates about the importance of the ACA and what impact its repeal might have on the nation’s health. And don’t forget to check out APHA’s updated fact sheet on why we need the ACA.

Q: The Affordable Care Act has delivered critically needed health benefits to millions of Americans. Can you list some of the top gains we’ve seen under the law?

When the ACA became law in 2010, but before its exchanges opened to sell subsidized insurance, more than 18 percent of people were uninsured, according to the Kaiser Family Foundation. In 2015, after the reforms of the ACA went into effect, the rate of people without health insurance had fallen to 10.5 percent. That means about 20 million Americans are newly insured through the ACA’s health exchanges.

The ACA has also helped improve health and cut costs. For example, one of its programs — the Partnership for Patients — which is dedicated to reducing hospital-acquired conditions, helped save 125,000 lives and $28.2 billion in health care costs from 2011 to 2015.

The ACA has also helped improve insurance coverage rates for racial and ethnic minority groups. The uninsured rate for African Americans decreased 7.7 percent from 2013, before the ACA’s health insurance plans became available, to 2015. Over the same period, the rate of Hispanics lacking health insurance dropped by 9.5 percent.

Q: What happens to those 20 million Americans who have gained health insurance under the law if it is repealed?

If the ACA is repealed, it will most likely be done through a process called budget reconciliation that allows Congress to repeal significant portions of the ACA if they have an impact on the federal budget. A budget reconciliation bill only requires a simple majority to pass in each the House and the Senate so it cannot be stopped by using a filibuster in the Senate. Important parts of the ACA cannot be repealed through this process, however, if they do not directly affect the budget. This means that Congress can’t use the reconciliation process to repeal the provision that prohibits insurance companies from discriminating against people with pre-existing health conditions, but subsidies to help buy insurance through the exchanges could be repealed, because they come from the federal budget. However, Congress also could pass additional legislation to eliminate other non-budget related portions of the ACA.

One situation that could happen is that healthy people will not buy insurance from the ACA marketplaces because subsidies will not be available. This would leave only people with health conditions in the market for insurance, and they use more health care and are more expensive to insure.  In response, insurance companies would increase costs. Some insurers may choose to stop selling health insurance plans on the ACA marketplaces altogether. The Urban Institute estimates about 4.3 million people could lose their insurance right away under this type of partial repeal.

Q: The ACA has helped to shift the focus of the nation’s health system from treatment toward prevention. What’s at stake from a prevention perspective?

The ACA enacted the Prevention and Public Health Fund, which is the only federal fund dedicated solely to prevention. Over the last several years, it has helped pay for a wide variety of public health activities in every state. This includes initiatives that detect and respond to infectious disease threats, prevent lead poisoning, fight obesity and curb tobacco use. Losing the Prevention Fund would be a step in the wrong direction, especially considering only about three percent of all health care spending is dedicated to prevention. In addition, the fund makes up about 12 percent of the budget at the Centers for Disease Control and Prevention and repealing it would leave a huge hole in CDC’s budget that would be difficult to restore with the existing budget caps on nondefense discretionary spending.

The ACA includes a lot of programs that test new ways of paying for and providing health care. Many of these programs stress prevention of serious health conditions, addressing the social determinants of health and providing health care outside hospitals. Not continuing these programs and searching for ways to make the health system focus on keeping people healthy, rather than treating emergencies, would be a mistake.