Commentary: Without the Affordable Care Act, the COVID-19 crisis would be far worse

Commentary: Without the Affordable Care Act, the COVID-19 crisis would be far worse

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This transmission electron microscope image shows SARS-CoV-2, the virus that causes COVID-19, isolated from a patient in the U.S., emerging from the surface of cells cultured in the lab.

This transmission electron microscope image shows SARS-CoV-2, the virus that causes COVID-19, isolated from a patient in the U.S., emerging from the surface of cells cultured in the lab. (NIAID/TNS)

In the midst of a global pandemic, President Barack Obama's signature health care reform, the Affordable Care Act, turned 10 years old. It has been under fire that entire time, with more than 70 legislative attempts to repeal or otherwise limit the law, not counting executive and judicial action to chip away at it. In its 2020-21 term, the U.S. Supreme Court will again decide whether to strike down the law in its entirety. But consider how much worse the fight against COVID-19 would be without the ACA.

To start, a lot more of us would be uninsured. In 2010, almost one-fifth of the population lacked health insurance - over 46 million people. The ACA endeavored to address that problem. Insurers now cannot turn down people for coverage because of preexisting conditions, nor charge them more. More people now qualify for Medicaid coverage, tax credits to help them purchase insurance on the exchanges or to stay on their parents' plans until they turn 26. Taken together, these efforts led to 20 million more people now having coverage if they need treatment for COVID-19.

Without insurance, research shows that many would lack the sort of relationship with a primary care physician that is essential for getting early advice about whether to get tested, whether to self-quarantine and whether to present at the hospital for emergent care. Disease would spread, and costs would go up for everyone.

But it's not just about who gets coverage. The ACA also has helped with the quality of coverage, by lowering out-of-pocket costs through subsidies and annual limits, and by requiring many plans to cover essential benefits, including doctors' services, inpatient and outpatient hospital care and prescription drug costs. Without the ACA, more plans would refuse reimbursement for the cost of COVID-19 treatment.

In the next 12-18 months, we hope that a vaccine for COVID-19 will be available. Even then, the world would look very different without the ACA. The law requires almost all private plans to cover preventive health services such as vaccines with no cost-sharing. Non-ACA plans, such as the short-term policies that the Trump administration has been promoting, are exempt from this requirement.

Still, the picture is far from perfect. Over 10% of the population lacks insurance coverage, and a recent survey found that 66% of the uninsured are worried that they will not be able to afford COVID-19 testing or treatment if they get sick.

Too many people still have to pay too much to get care. The Commonwealth Fund estimates that 44 million people are "underinsured" with huge deductibles, copays and coinsurance beyond their ability to pay. As one of us has shown in a new book, deductibles for employer plans have grown by 212%, or 10 times the rate of inflation. Just as with the uninsured, a 2013 study found that these costs can deter patients from accessing needed care.

On March 11, President Donald Trump said the insurance industry has "agreed to waive all copayments for COVID-19 treatment," but it was not true. In fact, as Vice President Mike Pence later tried to clarify, they only agreed to waive costs for tests, not treatments. Some health systems are stepping up to waive deductibles and copays on treatments; however, that scope remains to be seen.

Also, health insurers paying the high costs for COVID-19 testing and treatment will respond the only way they can, by raising premiums in 2021. California's ACA exchange has warned that premiums could go up by as much as 40%.

Nonetheless, we are certainly better off in the fight against COVID-19 with the ACA than we would have been without it. Some states are even now turning to the ACA for solutions. Since the pandemic began, more than nine states have announced that they will reopen their exchanges to allow uninsured residents to enroll. The Trump administration considered offering a special enrollment period specifically designated for COVID-19. After waffling on the issue, it came out the wrong way, deciding not to give the uninsured the opportunity to enroll.

Looking forward, the pandemic illustrates the dire need to focus on a rational health policy. We cannot move backward. A modest start would be to immediately pass legislation recreating a small penalty for those lacking health insurance. That would moot the pending Supreme Court case and save the ACA. Even better, Congress could address the uninsurance and underinsurance problems that don't exist in other developed countries. When the dust from the crisis settles, it will be time to get serious about health care reform.



Christopher Robertson is a law professor at University of Arizona and author of "Exposed: Why our Health Insurance is Incomplete and What Can Be Done About It" (Harvard University Press 2019). Wendy Netter Epstein is a law professor at the DePaul University College of Law and faculty director of the Jaharis Health Law Institute.

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