The U.S. Supreme Court heard oral arguments on Tuesday in a lawsuit challenging the Affordable Care Act.
More than 100,000 Mainers currently rely on the ACA for insurance, either through the marketplace or Medicaid expansion. Some estimates project that Maine would experience the highest increase in the uninsured rate in the country if the ACA is struck down. But the decade-old federal law has changed the U.S. health care system in other ways, so there’s more at stake for Maine if the law is repealed.
Patricia Washburn is a technical writer and IT contractor based in Portland. It’s contract work, so it doesn’t come with employer-based insurance.
“I’ve always been open to jobs with benefits, and occasionally I get them. But the way the industry works, a lot of the jobs out there are these contracts,” she says.
Washburn relies on the Affordable Care Act’s marketplace for insurance. She says it allows her to keep a great job and work from home, something she did even before the coronavirus pandemic because she has a disability and uses on a wheelchair.
“Health care access through the ACA has enabled me to remain productive even though my physical mobility has declined,” she says.
Washburn is one of more than 62,000 Mainers who currently buy insurance through the Affordable Care Act’s marketplace. She could lose it if the U.S. Supreme Court decides the entire law is unconstitutional. It would end the federal subsidies that more than 80 percent of Mainers who purchase marketplace plans rely on, says Kate Ende of Consumers for Affordable Health Care.
And federal funding for Medicaid expansion, which covers 90 percent of the tab, would also disappear. Nearly 65,000 Mainers have coverage though that program.
“The ACA is very far-reaching, and so to just completely get rid of it would cause chaos in our health care system,” Ende says.
State lawmakers have taken steps to shield Mainers from threats to dismantle the ACA. Last year, Gov. Janet Mills signed a bill that enshrines some of the ACA’s protections into state law. Things like requiring insurance companies to cover essential health benefits, allowing young adults to stay on their parents’ plans until age 26, and barring insurers from denying coverage to people with preexisting conditions.
Maine’s law protects some people, says Ende, but not everyone.
“There’s obviously still gaps that remain, which is why having that federal legislation is so important,” she says.
One of those gaps involves the fact that that not all employer-based insurance is regulated by the state. A little more than half of private-sector employees in Maine work for companies with self-insured plans, which are regulated by the federal government.
“So they don’t have to follow all of Maine’s laws. So we would still have people with employer coverage who would still be subject to a preexisting condition exclusion, for example,” Ende says.
The potential loss of protections and coverage are perhaps the biggest, most obvious issues at stake for consumers. But the ripple effects would extend to other areas of the health care system, says Jeff Austin of the Maine Hospital Association.
“The secondary impact is on providers. Particularly hospitals, which have the unique obligation to treat the uninsured,” he says.
Austin says the ACA has helped reduce hospital losses from charity care. And the prospect of patients losing coverage is particularly concerning during a pandemic.
“But even in a nonpandemic environment, people get sick and if they can’t pay, that falls to the hospital’s bottom line as a loss. And given the circumstances of a slowed down economy, and there were six months when hospitals weren’t doing very much in anticipation of a COVID spike, it would be a real financial hardship,” he says.
The ACA is also responsible for measures to improve quality, from data collection to payment methods that reward or penalize hospitals and providers. And Ende says the law has touched other aspects of life, from requiring nutrition information on menus in chain restaurants, to ensuring nursing mothers have a private space to pump breast milk at work, to free annual check ups and flu shots.
“Most people would be impacted by repealing the ACA in some way,” she says.
And for racial and ethnic minorities, a repeal of the law would exacerbate disparities in care. Lisa Sockabasin of Wabanaki Public Health says more indigenous people in Maine and across the country are insured now, thanks to the ACA.
“It’s critical in serving thousands, if not more indigenous people. And so in moving forward, if this should go away, we just have a greater disparity. A disparity that we’ve already experienced through generations of having inadequate health coverage and care,” she says.
The executive director of Lewiston-based New Mainers Public Health Initiative, Abdulkerim Said, says before the ACA, immigrants often had to go to emergency rooms for care. But now, they get treatment from primary care doctors.
“It will increase, again, the gaps that were existing before,” he says.
The ACA has faced challenges twice before in the Supreme Court. Justices have until June to issue a decision on the current lawsuit.