ACA Repeal Would Undo a Decade of Progress for People with Complex Health Needs

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As one of the youngest members of the Millennial generation, it’s difficult for me to recollect what the world looked like before the Affordable Care Act (ACA). That is a testament to how – almost ten years since its passage – the ACA has defined an entire generation’s concept of what health care is and ought to be.

By expanding care and coverage, the ACA was a milestone for communities most underserved by the health system. The law provides the core foundation for the work of the Center and our partners. In particular, the ACA includes a number of provisions that improve coverage and access to care for older adults and people with complex health care needs. These improvements in coverage are a critical foundation for a movement toward patient-centered policies, sustainable long-term care and quality primary care. The law also protects people with pre-existing health conditions, which includes anyone with complex health needs, from being denied or charged more for coverage.

The Health Care Repeal Lawsuit (Texas v. U.S.), by contrast, would dismantle these critical protections by overturning the ACA in its entirety. Last month, the 5th Circuit Court of Appeals ruled that the law’s individual mandate is unconstitutional and sent the case back to District Court Judge Reed O’Connor to determine what parts of the law remain intact and what parts fall with the mandate, if any. Eliminating the ACA would have devastating and life-threatening consequences for older adults and people with complex health needs, especially those who are “dually eligible” for Medicare and Medicaid coverage. Without the ACA’s infrastructure and legal protections, consumers with complex needs and older adults would be pushed farther to the margins. 

In addition to consumer protections for those with pre-existing conditions, the ACA includes a number of initiatives invaluable to the health coverage and quality of care for older adults and people with complex needs:

  • The ACA expanded health coverage, providing many low-income adults with greater coverage and access to care. In states that have expanded Medicaid eligibility, there are large increases in regular check-ups and other preventive care, more prescriptions filled for chronic conditions, and more adults with a primary care provider or a usual source of care. In the past six years, Medicaid expansion states have enrolled 13 million more adults, many of them older adults who would otherwise go without health insurance, due to the cost. A recent study found that Medicaid expansion prevented the premature deaths of at least 19,200 older adults aged 55 to 64 in a four-year period from 2014 to 2017. Without the ACA, primary care would be unaffordable and out of reach for many, especially low-income older adults.
  • Through its expansion of the Medicaid program, the ACA greatly expanded home and community-based services (HCBS). The ACA’s expansion of Medicaid and long-term services and supports (LTSS) programming has allowed more people to access the LTSS they need to live in a community setting. Due to the ACA’s creation of more opportunities to divert LTSS away from institutional settings, states have increasingly focused their LTSS funding on more community-based settings and now spend more than half of their LTSS dollars on HCBS. With about 70 percent of older adults projected to need LTSS services in their lifetime, the need for community-based supports is only increasing. 
  • The ACA created the infrastructure to improve care coordination for dual eligibles. Individuals who are eligible for both Medicare and Medicaid tend to have more significant health and functional support needs compared to people who are eligible for just one of these programs. Before the ACA, no federal office coordinated between Medicare and Medicaid, meaning that beneficiaries eligible for both programs had to navigate multiple sets of requirements, differing benefits and plans. The ACA created the Federal Coordinated Health Care Office (also known as the Medicare-Medicaid Coordination Office or MMCO), to improve care for dual-eligible beneficiaries.
  • The ACA greatly accelerated innovations in payment and delivery models focused on improving care coordination. The Center for Medicare & Medicaid Innovation (CMMI) is a federal agency that supports the development and testing of innovative health care payment and service delivery models that improve both quality and cost of care for consumers. Since its inception, CMMI has rolled out programs that are working to emphasize better coordination of care.

For my generation, it’s always been a given that the ACA will help provide people with disabilities and older adults the services and supports they need to live with dignity and with better choice over their care. For health care consumers of all ages, a repeal of the ACA would be a retreat back to the “dark ages” of health care, when those with pre-existing conditions and/or complex health needs were forced to go without coverage, care coordination, or adequate long-term supports. It would be a grave mistake to sacrifice these hard-fought gains and return to an archaic system. Although many of us were not around to advocate for the Affordable Care Act’s passage, it’s our turn to speak out to ensure its vital coverage expansions and consumer protections stay in place for generations to come.