Ever since the Affordable Care Act (ACA) was passed into law in 2010, members of Congress and the administration have been doing everything possible to repeal this important healthcare legislation. Another potential Supreme Court showdown impacting the ACA is on the horizon. Consequently, it got me thinking about ways the ACA impacts older Americans; in particular, how the ACA’s Medicaid expansion benefits older adults.

Medicaid is a cooperative, means-tested healthcare program that currently provides coverage to around 71 million people. It was created in 1965 to deliver medical care to various low-income populations, such as people 65 and older, children, adults and people with chronic disabilities. Because of the ACA, states have the option to expand Medicaid eligibility for people under the age of 65 with income up to 133 percent of the federal poverty level (FPL.)

So have older Americans benefited from the Affordable Care Act’s Medicaid expansion? The answer is a resounding yes!
For starters, the Urban Institute and the American Association of Retired People (AARP) report that because of the ACA’s Medicaid expansion and other reforms, the uninsured rate for older adults, ages 50 to 64, was cut in half by 2015. Also, the ACA’s premium tax credits have helped over 3 million people in this age range afford health insurance. This news isn’t just good for older adults before they turn 65, but is critical for when they are Medicare-eligible. As I reported in my blog, “Repealing and Replacing the Affordable Care Act and its Impact on Medicare,” evidence demonstrates that Medicare-eligible seniors with prior health insurance require less expensive health care than people who were uninsured before they enrolled in Medicare.

To further the point, the University of Michigan recently released a study that examined the impact Medicaid expansion had on the mortality rate of older adults (55 to 64 years old) in expansion states vs. non-expansion states. The study concluded that between 2014 and 2017, the ACA’s Medicaid expansion saved 19,200 older adults’ lives. Expansion could have prevented another 15,600 deaths in non-expansion states. Overall, I think the Center on Budget and Policy Priorities summed up Medicaid expansion best: “If all states had expanded Medicaid, the number of lives saved just among older adults in 2017 would roughly equal the number of lives that seatbelts saved among the full population, based on estimates from the National Highway Traffic Safety Commission.”

Furthermore, the study stated, “The estimated impact of the expansions increases over time, suggesting that prolonged exposure to Medicaid results in increasing health improvements.” Researchers reported that mortality reduction rates in Medicaid expansion states can be attributable to better health outcomes in the areas of cardiovascular disease, diabetes and early detections for breast and cervical cancers. I think it’s fair to conclude that government programs that expose more people to health care lead to healthier outcomes.

Strengthening the argument, last November, Kaiser Health News’ Laura Ungar, authored a fascinating article entitled “The Deep Divide: State Borders Create Medicaid Haves And Have-Nots” documenting the differences in health care between the states of Illinois and Missouri. While these two states lie right next to each other, only separated by the Mississippi River, the difference between their two Medicaid programs couldn’t be more different. For instance, the state of Illinois has reaped the benefits of Medicaid expansion by being able to provide health coverage to an additional 650,000 people, while Missouri’s decision not to expand Medicaid has denied health care coverage to 200,000 people. 

The article further highlights the point with a human interest story about Patricia Powers, a resident of Missouri, who lost her health insurance. Because she was unable to afford health insurance, she never visited a doctor and was unaware of the cancerous tumors in her breasts. In addition, she discontinued taking medicine for high blood pressure and anxiety, because it was cost prohibitive. What makes the story even more tragic is that if she lived in Illinois, she would have qualified for Medicaid. Eventually, in her early 60s, the cancer was discovered upon visiting Casa de Salud, a low-cost medical clinic in Missouri. Since Powers was ultimately diagnosed for breast cancer, she became eligible for Medicaid that allowed her to receive treatment for the disease.  

What makes the decision by some states not to expand Medicaid maddening is that often it’s significantly easier and cheaper to treat patients when the medical problem is in its infancy. Jorge Riopedre, president and CEO of Casa de Salud said, “Even if you didn’t care about the human cost, you should care about the economic cost. Treating a disease at its first stage is always going to be much cheaper than treating it at its advanced stage.”

Thankfully, Medicaid expansion advocates in the state of Missouri are trying to get the issue on the November 2020 ballot. We can only hope that after election day, thousands more Missourians will be eligible for health care coverage.
The benefits of the ACA don’t just stop with improving the rate the of insurance. They also extend to protections for people with pre-existing conditions and curtailing what insurance companies can charge older adults compared to younger people in the marketplace.
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Despite the millions of Americans that have benefited from the ACA, it continues to be under attack.  If the congressional ACA fights of 2017 taught us anything, it’s that Congress is no closer to agreeing on healthcare than they are on immigration, taxes or any other “hot button” issue. The benefits of the ACA in the older adult community can’t be denied any longer. However, we can only hope that once again, this legislation can withstand judicial scrutiny.

Currently the Affordable Care Act (ACA) protects people with pre-existing conditions by outlawing health insurance companies from refusing to sell plans to individuals because of existing health issues. These protections are particularly important for older Americans who obviously are more likely to have a pre-existing condition. Unfortunately, these protections could be compromised by Department of Justice’s (DOJ) decision not to defend the ACA’s in a lawsuit brought by Texas and 19 other states. The basic premise behind the litigation is that because of last year’s tax reform legislation, the individual mandate has been effectively eliminated because people will no longer be taxed for not carrying health insurance. Taken one step further, these 20 states argue that because the individual mandate is so integral to the ACA, that the rest of the legislation should be found unconstitutional (it should be noted the administration is only arguing pre-existing protections and community ratings should be found invalid). Currently around 25 million older Americans (50 to 64) could be denied insurance in the individual market if the protections for people with pre-existing health conditions are eliminated.   

First the DOJ’s  decision is concerning because it runs contrary to its own long standing tradition of generally defending federal law in litigation, even if the current administration is ideologically opposed to the policy. Law professor Nicholas Bagley from the University of Michigan who used to work at the DOJ said, “I am at a loss for words to explain how big of a deal this is. The Justice Department has a durable, long-standing, bipartisan commitment to defending the law when non-frivolous arguments can be made in its defense. This brief torches that commitment.”

In addition, in a letter from Attorney General Jeff Sessions to House Speaker Paul Ryan regarding this litigation, Sessions argues that without the individual mandate, “individuals could wait until they become sick to purchase insurance, thus driving up premiums for everyone else.” Meaning people could go without insurance until they become sick, and because of pre-existing conditions protections insurance companies would be forced to sell sick people policies, thus driving up the costs for everyone else. If I understand this correctly, Congress and the White House repeal the individual mandate, which will likely drive up health insurance premiums, and their solution to this problem is to deny protections for people with pre-existing conditions. 

While a final resolution regarding this litigation is a ways off, currently the ACA has been instrumental in providing improved health care protection and coverage for older Americans. For example, according to the Commonwealth Fund in 2010, 43 percent of individuals between the ages of 50 to 64 who attempted to purchase health care coverage where either rejected, charged higher premiums or had certain health conditions omitted from policies. The ACA combats these problems by not allowing people to be denied for pre-existing conditions, limiting what insurance companies can charge older Americans compared to younger people and regulating individual’s insurance premiums through tax credits. The Commonwealth Fund reports between 2012 to 2016 older Americans between 50 and 64 saw the uninsured rate drop from 13 to 8 percent. Clearly older Americans have seen substantial improvements in health insurance access since the ACA was enacted; eliminating protections for pre-existing conditions will inevitably cause older adults health care costs to increase.

Furthermore, as I have reported in my previous blog, Repealing and Replacing The Affordable Care Act And Its Impact on Medicare, older Americans who don’t have health insurance prior to turning 65 are more likely to require more expensive health care once they enroll in Medicare.  The Justice Department’s decision not to defend pre-existing conditions in litigation will only make older adults less healthy before they enroll in Medicare by potentially limiting access to health insurance.  

Lastly, this litigation flies in the face of public opinion. According to a Kaiser Family Foundation poll, support for pre-existing protections is solid across the political spectrum with support amongst 84 percent of Democrats, 68 percent of Independents and 59 percent of Republicans.

Thankfully, the ACA is still standing and our elected officials in Washington, D.C. have been unable to repeal and replace the ACA. Realizing that a legislative repeal of the ACA might be unworkable, everything has been done to weaken this legislation. The administration has drastically reduced the ACA’s advertising budget, eliminated the cost-sharing subsidies and expanded short-term health plans which don’t offer key ACA protections.

Sadly, the current lawsuit’s end result could potentially strip away basic health care protections for older Americans. What happens if the court sides with the plaintiffs and gets rid of pre-existing conditions protections? Are older Americans expected to go back to a health care system where their plans are more expensive and protections are less stringent? Let’s hope for the sake of all Americans our court system protects safeguards put in place by the ACA for people with pre-existing protections.