During Pandemic Crisis, ACA's Role in Providing Coverage Highlighted as Landmark Law Turns 10

The Affordable Care Act (ACA) turned a decade old today, and while the anniversaries of landmark legislation are often marked in some fashion, that isn’t exactly happening this year.

In the wake of the coronavirus pandemic that is infecting thousands of Americans, 9 states that run their own healthcare exchanges—set up under the ACA—are reopening the window for individuals seeking to enroll in marketplace insurance. COVID-19, the disease, is caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2)

Last week, 29 patient organizations representing individuals with chronic health conditions—making them particularly vulnerable to COVID-19—called on the Trump administration to reopen HealthCare.gov for anyone in the United States affected by the pandemic and allow them to enroll. Most Americans have health insurance through employer-based insurance, but last week, jobless claims rose 70,000 due to layoffs attributed to the pandemic.

Open enrollment for most states ended December 15, 2019, and unless there has been a change in life circumstance, most people have to wait until enrollment opens up each November. A special enrollment period would help ensure individuals don’t delay getting tested or treated because they lack health insurance.

The Wall Street Journal reported over the weekend that CMS is considering reopening enrollment nationwide.

Through the exchanges, individuals can purchase health insurance coverage; last year, 11.4 million people enrolled in coverage through state and federal marketplaces. In addition, the ACA expanded Medicaid coverage to adults up to 138% of the federal poverty level (FPL). Between 2013 and 2019, enrollment in Medicaid expansion states, of which there are 36, plus Washington DC, increased by 13.1 million people.

Besides calling on Congress to pass the Families First Coronavirus Response Act—which it did last week—the patient organizations also called on the federal government to undo some of the actions the Trump administration has taken to curb the ACA since 2017. Although the administration failed in its effort to repeal the law, it created a number of policy measures to curb it.

The organizations noted that more Americans are signed up for insurance plans—short-term, limited-duration health plans and association health plans, as well as faith-based plans—that are not as robust as those that are compliant with the ACA.

Citing the economic impact of the pandemic, the organizations also asked that waivers establishing state Medicaid work requirements and eliminating retroactive eligibility be ended. Medicaid work requirements, allowed since January 2018 by CMS, require beneficiaries to work, volunteer, or be in school for a certain number of hours per month, depending on the state. But these have been the subject of several lawsuits and are largely on hold.

The organizations also want the administration to end its efforts to transform the Medicaid program to a block grant. "This public health crisis is likely to dramatically increase state Medicaid spending needs," the letter read.

Meanwhile, many health insurers are moving to waive copays for diagnostic testing or cost-sharing for some treatment related to the virus. The Families First act also includes provisions requiring health insurers to waive cost-sharing for COVID-19 testing services. However, there is not a provision for those who lack insurance.

The Supreme Court will hear California v Texas this fall after the election; if it agrees with Texas and the administration that the ACA is unconstitutional, Americans with preexisting conditions will lose their consumer protections and young adults would not be able to stay on their parent's plans until age 26. Medicaid expansion, which has led to earlier cancer diagnoses, lower maternal mortality rates, and fewer cardiovascular deaths, would end.

In addition, the mechanism for value-based care, the Center for Medicare and Medicaid Innovation, would have no authority to exist, nor would the Biologics Price Competition and Innovation Act of 2009, which created the pathway for which lower-priced biosimilars could enter the market.