After passing both houses of Congress, the Republican tax bill was approved in conference committee with a final vote expected before Christmas. The House approved the Senate's inclusion of a repeal of the Affordable Care Act's individual mandate, misrepresenting the mandate as an unfair tax on healthy Americans.
The tax bill gives large tax breaks to the wealthy and large corporations, increasing the deficit by as much as $1.4 trillion in the process, according to one projection. To reduce this shortfall, the Senate and now the House decided to discourage Americans from buying health insurance, thus reducing the subsidy payments that keep the plans affordable, especially for low-income individuals and families.
The ACA was designed to provide health insurance to over 44 million Americans who were previously unable to purchase plans due to even minor pre-existing conditions and prohibitive premiums. As of this year, 18 million people have purchased coverage in the individual market: 10 million enrolled on federal and state exchanges and more than 8 million enrolled off the exchanges. More than 4 million young adults under age 26 are now covered on their parents' plan. Expanded Medicaid covers approximately 13 million people who live in 31 expansion states and the District of Columbia, with an additional 2.5 million now enrolled in traditional Medicaid thanks to ACA outreach.
According to the American Hospital Association, increased coverage during the first two years of the ACA resulted in a $10.7 billion reduction in uncompensated medical care at community hospitals (from 5.3% of operating costs to 4.2%). Similarly, the Commonwealth Fund reported that uncompensated care for hospitals with a low to medium Medicaid population decreased from 3.9% of operating costs to 2.3%, while those with a higher percentage of Medicaid fell from 6.2% to 3.7%.
The Congressional Budget Office has reported that repeal of the individual mandate would result in 13 million losing insurance and an increase in premiums of 10% as the risk pool loses healthier enrollees. Several reports from healthcare economists indicate that the numbers are lower. Without a process to determine whether enrollment was for the sole purpose of avoiding the tax penalty, accurate numbers cannot be assessed. There are many reasons why millions have purchased insurance on the individual market irrespective of the penalty.
Despite misinformation from legislative saboteurs, the ACA plans have always been affordable, especially for those with incomes below 400% of the poverty level. Inexpensive catastrophic plans are available to those ages 30 and under. Bronze plans with higher deductibles are for those who don't expect high medical expenses. This year, hundreds of counties in over 30 states have bronze plans with zero premiums. The Kaiser Family Foundation reports that 5.9 million of the 10.7 million Americans who are eligible for ACA plans and remain uninsured would pay less in premiums than a tax penalty. About 42% of those could purchase a bronze plan for 2018 at no cost.
One provision of the ACA that's still not widely known is the requirement for insurers to cover annual preventive care 100% pre-deductible, including doctors' visits, lab tests and cancer screening, which otherwise could cost families thousands of dollars.
Young people don't realize that they still face a risk for diseases such as hypertension, diabetes and even certain cancers. Or if they do understand the risks they just shrug them off. They're called "young invincibles" for a reason.
Annual preventive care results in early diagnosis and treatment that reduces hospitalization and unreimbursed medical costs. For example, the September 2010 ACA requirement for insurers to cover annual mammograms 100% pre-deducible is credited with a reduction in the incidence of advanced breast cancer by January 2014. Without coverage, even young healthy individuals risk putting their families in devastating debt. Prior to the ACA, 62% of bankruptcies were due to medical expenses now reduced to half, according to the American Bankruptcy Institute.
The individual mandate may have encouraged millions to purchase health insurance, but efforts to increase education and counteract misinformation is what will keep them in the market and increase the number of new enrollees. Unfortunately, the Trump administration's continued attempts to impede enrollment—including cutting the three-month enrollment period in half and slashing the budget for outreach, education and enrollment guidance—was clearly meant to weaken the ACA. Despite these efforts, nearly 1 million new enrollees had purchased 2018 exchange plans as of Dec. 1. They obviously know the facts.
Dr. Rebecca Quigg is a cardiologist, healthcare reform policy advocate and former Democratic candidate for Congress in Georgia. Jack Bernard is a retired healthcare corporation executive and former state director of health planning in Georgia.