Open enrollment in New York’s Affordable Care Act marketplace is starting up again on November 1st. And, on the tenth anniversary of the passage of the ACA, its survival is arguably nothing short of a miracle.
The ACA weathered a case challenging its constitutionality in the Supreme Court in 2012; survived Congressional Republicans’ aggressive campaign to repeal the law after President Donald Trump took office; and it even withstood Congress eliminating the penalty for not having insurance (known as the individual mandate), which was once considered essential for the insurance market to function.
This year, the Trump administration has doggedly supported Texas’ challenge to the ACA that’s pending in the Supreme Court, even though repealing the law without a contingency plan would leave some 20 million Americans uninsured in the middle of a pandemic. The confirmation of conservative Supreme Court Justice Amy Coney Barrett this week has heightened the threat that case poses for those who rely on the ACA. (Oral arguments in the case will be heard on November 10.)
New York was already more generous in providing health coverage for low-income residents before the law took effect than most states, yet the ACA still helped cut the share of New Yorkers who are uninsured in half. Some 5.4% of the state’s population were uninsured in 2018, down from 10.7% in 2013, the year before the ACA went into effect. The ACA also provided billions of dollars in additional federal funding for free and reduced-cost health coverage, which would be difficult to replace given the massive budget deficit the state currently faces.
Still, for all the progress that has been made in expanding and protecting health coverage under the ACA, it’s not without its limitations.
Gothamist/WNYC has spent the past year collaborating with the company ClearHealthCosts to create snapshots of a health system that can be expensive, unpredictable, and downright scammy, even with the ACA in place. Our crowdsourced project PriceCheckNYC has been a small contribution to a larger effort by journalists in recent years to document the lack of transparency or consistency in health care pricing, the convoluted nature of health care billing, and the way in which these problems with the system place patients in constant fear that going to the doctor will drain their bank accounts, even if they have insurance.
Meanwhile, the COVID-19 pandemic has served to illuminate the deep inequality that persists within health care, as well as the challenges of addressing a public health crisis under such a fractured system.
With that in mind, here are a few things the ACA has — and hasn’t — done for New Yorkers:
The ACA expanded access to health insurance.
One in three New Yorkers statewide is enrolled in Medicaid, which is a free, public health plan that occasionally charges, if any, very low co-pays. New York was already more generous with Medicaid than most states before the ACA was passed, but the ACA made it possible to further extend eligibility and for the federal government to pick up more of the cost. New York is also one of two states that took advantage of the option under the ACA to create a basic health plan–here known as the Essential Plan–for people with lower incomes who don’t qualify for Medicaid.
The Essential Plan, paid for through federal funding, provided coverage that was either free or $20 per month to nearly 800,000 New Yorkers as of February of this year, and added more than 16,000 members in the early months of the pandemic.
The ACA’s online health insurance marketplace also provides premium subsidies to people with higher incomes and, without the law, it’s likely more people would opt out of getting insured for lack of affordability. Thanks to the ACA, most of those who lost employer-sponsored insurance during the pandemic qualify for Medicaid or subsidized health insurance.
Yet the ACA has not made health care affordable for everyone.
Even as the ACA has expanded access to health insurance in New York, some still find it too expensive, particularly since the cheapest plans tend to offer the worst coverage. Some New Yorkers–typically those earning around $50,000 per year–have fallen off what the Kaiser Family Foundation refers to as the “subsidy cliff,” meaning they earn too much for government assistance and too little to comfortably afford premiums on even the cheapest plans with the highest deductibles.
Several of those who spoke to Gothamist/WNYC about their health coverage over the past year were enrolled in an ACA plan because they were self-employed. The ACA prevented them from becoming uninsured, but some still said their fluctuating incomes made it difficult to shop for and afford coverage.
Many who are insured find that they’re still responsible for outsized medical bills when they do seek care, without knowing what they will pay ahead of time. One New Yorker, whose story didn’t make it into PriceCheckNYC coverage, cut his hand and went to the emergency room at Mount Sinai Morningside hospital last year, thinking the wound was more serious than it actually was. His cut was sealed up with liquid bandage, priced under $5 at CVS. The patient, an Oscar Health member, then received a bill for $1,430.96.
Gothamist/WNYC determined that the bulk of that fee — $1,220.04 — was the baseline rate Oscar had negotiated for a member to visit the ER at Mount Sinai (the charge for “doctor service” was separate). Of course, such negotiated rates are considered proprietary information, and therefore kept secret. The lack of transparency is normal.
The ACA created new coverage requirements for health insurers, which New York has added greater protections toward.
Perhaps the most important and well-known consumer protection put in place under the ACA was the requirement that health plans provide coverage for people with pre-existing conditions, such as diabetes or heart disease, without making them pay higher premiums (given its potential long-term effects, COVID-19 could also soon be considered a pre-existing condition).
But the ACA also put in place a range of other coverage requirements that have improved access to care and promoted public health. These include coverage for things like free birth control (something the Trump administration has chipped away at) and cancer screenings.
Governor Andrew Cuomo and the state legislature have put in place measures to reinforce and strengthen these mandates in recent years to protect them from a potential repeal of the ACA and to signal resistance to the Trump administration. Such fail-safes have their limitations, though. Because state law doesn’t apply to all health plans, the ACA still reaches more people.
But insurance mandates, including those related to COVID-19, can have spotty results.
Under the current system, in which everyone is covered by a different health plan and some people are still uninsured, it’s hard to create universal standards for health care access. Coverage mandates tend to come with caveats, making it hard for patients to tell whether the bill they received is valid.
To give one example from the PriceCheckNYC archives, a breast cancer screening is free under the ACA, unless it includes a test other than a mammogram. New York now requires insurers to cover other tests as well, but some health plans don’t have to because they’re governed by federal rather than state law. Health care providers don’t have to tell patients what a procedure might cost ahead of time, and, if asked, they often will legitimately not know.
Because health care billing rules are so complicated, each insurer and health care provider may interpret them differently, or flaunt them altogether, with little consequence. When there’s a disconnect, they tend to blame each other, leaving the patient in the middle.
The fact that it’s so hard to track and enforce insurance mandates has made them a relatively weak tool for trying to improve access to health care during a crisis like the COVID-19 pandemic. Yet, such mandates are the primary tool federal and state lawmakers have had to rely on because much of the funding for health care is funneled through insurers.
For instance, Cuomo mandated access to free telehealth visits early on in the pandemic in order to allow more people to receive care without leaving their homes. But how each visit got paid for without putting the burden on the patient was up to insurers and doctors to figure out. Inevitably, some patients still got charged. Results have been similarly spotty with the law Congress passed to give patients access to free coronavirus tests.
Many of those who spoke to Gothamist/WNYC about their health bills have said confusion and uncertainty inherent to the health system discourages them from seeking care.
The ACA has created new revenue streams for hospitals serving low-income patients.
Under the ACA, low-income patients are less likely to be uninsured, meaning the so-called “safety-net” hospitals that often serve them are reimbursed by insurance for more of the care they provide. In general, the ACA improved the financial stability of safety-net institutions in states that opted to expand access to Medicaid.
But safety-net hospitals are still disadvantaged.
In New York City there are still more than 500,000 people who can’t access health insurance because of their immigration status, many of whom rely on the public hospital system and other safety-net facilities for care. Meanwhile, patients who are insured through Medicaid still don’t bring in as much funding for hospitals as privately-insured patients because Medicaid pays lower rates for the same care. Generally, the more privately-insured patients a hospital serves, the more financially stable it is and the better resourced.
That means that, even with more people insured under the ACA, there remains deep structural inequality within the health system—something that has been on display in full force during the pandemic.
The fight for health care reform continues.
Ultimately, the ACA has done a lot to improve health coverage and consumer protections in the U.S. and in New York, specifically, in recent years. Even many Republicans are hesitant to put their weight behind a case that would throw the ACA out completely.
But there are also a lot of deep-rooted problems with the health system that have been left to fester. Both Republicans and Democrats have recognized the need for radical change to the health system, albeit with different strategies in mind.
U.S. Senator Bernie Sanders and other progressive Democrats have pushed Medicare for All, a model that has many variations (including a state version known as the New York Health Act), but in its purest form, would create a single government health plan for everyone.
Meanwhile, the Trump administration and Republican lawmakers, preferring a market-based solution, have sought to shift health care reform efforts towards creating full transparency in health pricing, a move hospitals and insurers a are resisting. They argue that a true health care market would empower consumers to shop for the best prices and foster competition, thus driving down costs (although what would actually happen remains unclear).
Democratic presidential candidate Joe Biden has simply promised to protect the ACA and expand it, partly by creating a public insurance option that anyone could opt into.
The next Supreme Court hearing on the case challenging the ACA will be held on November 10th.