Katelyn Watters

Professor Jennifer Santiago

UWRT 1102-027

30 March 2017

Repealing the Affordable Care Act: Effects on Vulnerable Populations

Since the Affordable Care Act's implementation in 2010, it has been at the dead center of

nationwide controversy. While studies show that the Affordable Care Act, commonly referred to

as the ACA, is supported by over half of Americans, the majority of Republican politicians have

advocated for its repeal since the day of its debut (Dalen et al. 807). The ACAs primary goals are

to improve the health of Americans by increasing their access to health insurance, improve the

quality of care, and reduce the high costs of care (Dalen et al. 807). So far, the ACA has proved

itself to be quite effective, as it has provided a net total of 16.9 million previously uninsured

Americans with coverage as of 2015 (Health Insurance Grows). There is no doubt that this is a

substantial number, which makes the talk of a repeal increasingly concerning, often proposing

the question: if the ACA were repealed, how would this impact the American public? It has been

found that many of these newly insured Americans are vulnerable, as they are oftentimes

economically disadvantaged, burdened with chronic illnesses, or a part of a racial or ethnic

minority (Steinbrook, et al.). A repeal of the Affordable Care Act would have a significantly

negative impact on Americas vulnerable populations, particularly low-income individuals, as

they would lose their access to readily available affordable health care.

The Affordable Care Act is an act that was passed March of 2010 that successfully

extends affordable health coverage to millions of previously uninsured Americans. This is mainly

due to its provisions for state-based Medicaid expansion and subsidies to assist middle and lower
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income individuals in purchasing private health insurance (Affordable Care Act History). An idea

to overhaul the American health care system to implement a nationwide healthcare structure is

hardly new, it just was not successfully executed until former President Barack Obamas time in

office (Affordable Care Act History). A considerable number of Americans across the political

spectrum were discontented with the state of the health care system prior to the ACA, and called

for a change.

The state of Americas healthcare system prior to the ACA was plagued with problems,

with many private insurance companies having the freedom to deny those with pre-existing

conditions, and drop peoples coverage when they reached their lifetime limits (Basu).

Employer-based insurance is and has been the most widely utilized health coverage outlet in

America (Health Insurance). A noteworthy downfall to this popular system is that employer-

based health insurance can sometimes entail a lack of options, as many employers have only a

select amount of health care plans for their employees to choose from (Basu 5). The health care

options provided might not be suitable for every specific individuals health care needs (Basu 5).

Prior to the ACA, if an individual were to lose their job or choose to take time off, they would

then need to find coverage through the individual market (Basu 5). If one were to develop a

medical condition after leaving their previous employer, they would be subject to higher

premiums or denial when applying for insurance due their pre-existing condition (Basu 5). This

system was problematic for many, especially those unemployed or with chronic illnesses (Basu

5). The inequalities that those groups faced when seeking coverage was one of the driving forces

in the institution of new health care reform. After the ACA was passed in Congress, it granted

protections for the public from harmful insurance practices, which was one of its fundamental

objectives when adopted into law (Dalen et al. 807).

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One of the ACAs most significant provisions is a mandate, called the individual shared

responsibility payment, that requires Americans to obtain health coverage, or else pay a penalty

(Eibner and Price). The mandate is perhaps one of the ACAs components most riddled in

controversy. Opponents argue that the mandate infringes on individual rights, and often call the

mandate unconstitutional (Eibner and Price). Proponents for the law claim that without the

mandate, millions who would have otherwise signed up for coverage would be uninsured (Eibner

and Price). This debate emerges into conversations all over the nation between politicians,

healthcare providers, and citizens of all classes, with many taking vastly different stances. With

all arguments set aside, the evidence is clear. Without healthy individuals paying into the health

care system, there will not be enough funds to cover those who need frequent treatment (Eibner

and Price). By requiring that Americans acquire health insurance or pay a fine, it eliminates the

facile route to forgo coverage in the hopes that one will remain in optimal health. Ideally, with

healthy and ill Americans paying their premiums, there will be enough revenue to adequately

cover individuals when treatment is necessary (Eibner and Price). If the mandate were repealed

and enrollment rates were to fall, there would not be enough funds to cover those who need

costly coverage. If one were to be involved in an accident or fall ill, their insurance plan would

likely be unable to cover the costs of their medical treatment adequately, leaving them with out-

of-pocket costs. For many, particularly low income populations, the ability to pay their debt is

oftentimes out of the question. Not only do situations such as this weigh these groups with

financial burdens, but it greatly decreases their chances of successfully getting out of poverty.

Medicaid expansion has had one of the most profound impacts on the vulnerable

populations access to affordable coverage (Hoadley and Searing). The Affordable Care Act does

not require, but instead encourages states to expand their Medicaid programs through generous
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federal funding incentives to assist in the management of costs for the coverage of new

individuals (Brandon). Beginning in 2014, all individuals in families with a modified adjusted

gross income of 138% federal poverty line or less who are under the age of sixty-five and not

already covered, are permitted to enroll in Medicaid (Brandon). This number is referring to states

that have opted to expand their Medicaid programs and accept the federal funding. Prior to the

provisions in the ACA, many low income groups found themselves ineligible due Medicaids

specific restrictions and variance across state lines (Brandon). States that have expanded their

Medicaid programs have experienced an increase in ability to provide healthcare to vulnerable

populations more successfully (Hoadley and Searing). Medicaid recipients in these states no

longer grapple with daunting medical bills, in turn assisting the financial bottom line for safety-

net clinics and hospitals, as patients are more likely to pay for their care due to their improved

financial status (Hoadley and Searing). The money that hospitals would have traditionally had to

use to cover uncompensated care can instead be invested in efforts to provide improved care and

preventative treatment (Hoadley and Searing). With money being invested in programs such as

these, it facilities research, further increasing the rate of the development of improved treatment

methods. Less money spent on uncompensated care eventually leads to better overall health

outcomes for virtually all groups.

Since the ACA was in its infancy, there has been disagreement on all ends of the political

spectrum (Dalen, et al. 808). Health care policy is an highly complex partisan issue, and

oftentimes does not have a solution that will be mutually agreed upon by all parties involved.

When the Affordable Care Act was passed by Democratic majorities in the House and Senate,

219 out of 253 Democratic party leaders voted yes, with all Republican party leaders voting no

(Dalen, et al. 808). Many opponents of the ACA argue the individual mandate is unconstitutional,
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the ACA has put insurance premiums on the rise, and that it is not the sole responsibility of the

federal government to ensure that Americans have access to healthcare (Dalen, et al. 809). While

there are many facets to the effects of the ACA that must be considered, it is undeniable that the

implementation of the ACA has had an overwhelmingly positive impact on low-income in

America (Dalen, et al. 808). More than 10 million individuals gained health insurance in 2014

alone that would have otherwise remained uninsured due to the Affordable Care Act (Dalen, et

al. 808).

By merely observing the facts, it is apparent that the Affordable Care Act has had a

profoundly positive impact on a large number of Americans. However, based on approval ratings

(Dalen et al. 808), heavy opposition is being heard from Americans nationwide. With this

information in mind, it poses a pertinent question: If the ACA has had such success in providing

affordable coverage to uninsured Americans as the evidence suggests, where is all this opposition

stemming from? It is likely that biased media influence plays a key role in the nations approval

of the Affordable Care Act. In a study referenced in the article titled, Why Do So Many

Americans Oppose the Affordable Care Act, it is found that after the ACA was fully

implemented in 2014, its overall approval ratings decreased by six percent from 2013, with fifty-

five percent of Americans being opposed to the individual mandate (Dalen et al. 808-809). It was

also found that in 2014, only forty-five percent of Americans believed that it was the

responsibility of the government to ensure its citizens had access to health coverage (Dalen et al.

808). This study also reports that sixty percent of Americans reported that the information they

had about the ACA was delivered to them via the television, with ninety-four percent of the $445

million spent on television advertising for the ACA in 2014 being used to display negative

images and information (Dalen et al. 808-809). This is alarming, as it is widely recognized that
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numerous media outlets have their own personal, political, and financial agendas to push. With

the spread of biased, or inaccurate information, viewers that have no background knowledge

regarding health care policy can be easily persuaded into choosing a side. The stance they take,

when based on biased or falsehoods, can be damaging to large groups of people, especially low

income populations, as it directly decreases vulnerable Americans access to affordable health

care due to the likelihood of elected officials coming into power that will work to dismantle or

repeal beneficial programs such as the ACA. Without Americans being exposed to the legitimate

effects of the ACA through reliable facts and statistics, it is unlikely that America will achieve

universal health care at any point in the near future.

Throughout the course of the 2015-2016 presidential campaign, a dismantle or repeal was

an action promised by nearly every Republican in the race (Carroll). Opponents were ecstatic,

often believing that it would lower their premiums (Dalen et al. 808), promote employment

(Dalen et al. 808), and reinstitute autonomy for Americans when making the decision to purchase

healthcare. Speaker of the House, Paul Ryan, has recently proposed a popular plan that has met

the demands of many Republicans nationwide titled the A Better Way plan, which is backed by

Republican politicians across America, who also, in some cases, are proposing similar health

care plans of their own (Carroll). A Better Way would allow insurance companies to charge

new beneficiaries a price set by the company if the individual did not have continued coverage

(Carroll). This is problematic, because if people were to lose their continued coverage, due to

loss of employment, for example, they would have to turn to high risk pools (Carroll), locking

them out of the individual market due to a pre-existing condition. It would also proposes to

change Medicaid to a block grant program, which is a federal grant system for states to use for

social welfare programs (Carroll). This money would be granted to states, leaving states with the
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authority to make the tough calls as to who will be covered, how much coverage will be granted,

as well as how to utilize funds more efficiently (Carroll). Because a block grant is a set amount

of money, if states were to expend over the allotted amount, they would have to cover costs with

outside resources, likely having to tap into their own revenue. This would likely result in the cut

of services for vulnerable populations, as the money for the block grant would not entirely cover

their expenses. Additionally, if the block grant were less than the amount that the state is already

spending on Medicaid, residents would lose access to certain services or even lose their

eligibility entirely due to the internal system changes that would likely have to occur due to the

lack of funds. Low income individuals would suffer the most from a redesign such as this, as

they are oftentimes heavily dependent on the health care services offered by Medicaid. Inability

to access care could only lead to higher mortality rates, uncompensated care costs, and a general

decrease in the quality of life for many individuals.

Low income individuals make up a hefty portion of America, with approximately 15.2%

of Americans being below the poverty line in 2015 (Bureau). As of 2016, low income individuals

are usually recognized as having a pre-taxed income below $11,770 (Federal Poverty). For each

individual in one family, $4,160 is allotted to the previous amount (Federal Poverty). For

example, a single individual with one child that makes less than $15,930 is one-hundred percent

of the federal poverty level, or below the poverty line (Federal Poverty). The Medicaid eligibility

standard is 138% of the federal poverty level, so a single parent of one child can earn up to

$16,394 and still remain eligible for Medicaid in terms of annual income (Federal Poverty). This

is important to note, as the rank of an individuals income, according to the standards set by the

government, will determine how much federal assistance they will be given. For the purposes of
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this discussion, low-income individuals will be further subdivided into the unemployed, low

income women, and the homeless.

With the national unemployment rate being nearly ten percent when the Affordable Care

Act was passed in 2010 (State Unemployment), a key objective of the ACA was to assist

unemployed individuals in obtaining affordable coverage. It has proven successful, as the

Affordable Care Act has assisted a net total of 16.9 million Americans in obtaining affordable

coverage, with many of those individuals being unemployed (Health Insurance Grows). As

previously stated, employer-based insurance remains the most widely utilized health coverage

outlet in America (Health Insurance). When an individual loses their job, they customarily lose

their health insurance as well, leaving them unprotected in the event of a medical emergency

(Health Insurance). Prior to the ACA, they would be forced to fork up the money to pay for

private insurance off the individual market, usually having to pay exorbitant premiums,

particularly if said person has developed an pre-existing condition (Health Insurance). However,

since the implementation of the ACA, when an individual purchases insurance from the

individual market, occasionally referred to as the Health Insurance Marketplace, insurance

companies cannot deny an individual or install waiting periods (Eibner and Saltzman). In

addition to those protections, premium tax credits are now oftentimes offered for those wishing

to purchase private insurance (Eibner and Saltzman). Premium tax credits are refundable tax

credits that alleviate the high costs of insurance off the Health Insurance Marketplace for eligible

individuals and families with low to moderate income levels (Questions and Answers). These tax

credits have proved to be incredibly beneficial for those who do not qualify to Medicaid, yet

cannot afford unsubsidized premium rates and out of pocket costs that come with private

insurance (Questions and Answers). Along with the individual mandate, these tax credits
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encourage unemployed or lower income individuals who would otherwise forgo purchasing

insurance to get covered (Eibner and Saltzman). With more people being a part of the system, the

market is stabilized, protecting subsidized enrollees from premium increases (Eibner and

Saltzman). According to a COMPARE-based analysis, a repeal would create a cessation in tax

credits and abolish the mandate repeal, in turn causing considerable decreases in enrollment rates

and a steady incline of premium costs (Eibner and Saltzman). The analysis estimated that

unsubsidized premiums would rise by 43.3 percent, with enrollment falling by 68 percent,

leading to 11.3 million Americans becoming uninsured (Eibner and Saltzman). In a circumstance

such as this, low-income and unemployed individuals will be priced out of the market, leaving

them unprotected without insurance. Their inaccessibility to necessary health care would only

lead to higher uncompensated costs for hospitals, and overall poorer health outcomes for these

individuals.

Low income women are a large group faced with a multitude of issues regarding the

deliverance of affordable care, particularly reproductive care. Since the Affordable Care Act has

been implemented, increased access to affordable reproductive care was made accessible for low

income women (Fox and Barfield). Unintended pregnancy rates are highly associated with low

income levels (Henshaw 27), and are oftentimes accompanied by delayed prenatal treatment and

fetal exposures to tobacco and alcohol (Fox and Barfield). These factors combine to result in

adverse health outcomes for both the mother and child, as well as poorer social and economic

outcomes overall (Fox and Barfield). There are approximately 2.8 million unintended

pregnancies every year in the U.S., and while on the decline, more than 430,000 of these

pregnancies occur among adolescents from ages 15 to 19 (Fox and Barfield). The ACA has

worked to decrease unintended pregnancy rates by removing cost barriers for LARC, long-acting
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reversible contraception, along with providing services to women such as education and

counseling at no cost (Fox and Barfield). The requirement of insurance companies to provide a

variety of preventative services without cost sharing by the ACA has proven to be effective, but

continues to face challenges due to problematic policies involving reimbursement for health care

providers and overall lack of awareness of the accessibility (Fox and Barfield). If the Affordable

Care Act were to be repealed, it would reverse the improvements that have been made by

decreasing accessibility for those dependent on these LARC methods, in turn likely raising the

unintended pregnancy rates in America. Unintended pregnancies often involve underprepared

mothers, who are usually not in a comfortable position to adequately support a child/ren

financially. Due to this, these children will likely have poorer health outcomes than children

living in households with higher annual earnings, as access to health care could potentially be an

obstacle. Additionally, an underprepared household may not have the dynamic to model healthy

behaviors for young children. Women having access to LARC methods have proven the most

effective, allow for women to have more control over their reproductive decisions, and has the

best health outcomes for both the mother and baby.

The homeless population in America is not only low income, but perhaps one of the most

vulnerable populations in America, with 1.2 million Americans facing homelessness every year

(Fryling, et al.). Homelessness is generally defined as the absence of stable housing for more

than two months, examples include but are not limited to sleeping in a car, outside, or in a shelter

(Fryling, et al.). Medicaid expansion under the ACA was designed with vulnerable populations at

the forefront, striving to improve their accessibility to affordable health care. Most homeless

Americans are eligible for Medicaid, however, this is not always made clear to them (Fryling, et

al.). A study was conducted in 2014, a thirty-question survey that was comprised of questions
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about their access to communication, awareness of the ACA, insurance status, and obstacles

when attempting to obtain coverage was given to 650 participants over a ten week period

(Fryling, et al.). All adult patients in treatment areas of the emergency department at San

Francisco General Hospital on weekdays between 9:00 a.m. and 5:00 p.m. were considered for

enrollment, with 121 of the 650 participants being homeless (Fryling, et al.). Compared to the

survey results of the non-homeless population, homeless individuals report having less

knowledge about the ACA, a weaker understanding of the ACA and its enrollment process and

qualification requirements, as well an increased lack of internet access (Fryling, et al.). 70% of

the homeless subjects were unaware that they qualified for Medicaid, with 91% of these unsure

subjects reporting income levels below 138% of the federal poverty line, likely making them

eligible (Fryling, et al.). However, awareness measures have been taken to enroll homeless

individuals, with service providers playing a significant role by assisting these individuals with

insurance applications and strengthening connections to regular sources of health care

(Winetrobe 147). The ACA has instilled changes in the healthcare system that enable these

populations to access vital health care (Fryling, et al.). In addition to significantly poorer health

outcomes and a lack of improvement in life expectancy rates, a repeal also would result in higher

uncompensated ED costs due to the inability of homeless populations to see primary care

physicians (Fryling, et al.). The ACA has improved their ability to access services to improve

their general welfare, visit primary care physicians for preventative care, alleviate pain, and

increase their lifespan. Without Medicaid expansion, many homeless individuals would not have

qualified for Medicaid, making their ability to seek health care incredibly expensive and, at many

times, inaccessible.
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With an estimated 15.2% of the population living below the federal poverty line in

America (Bureau), it is critical that these individuals be regarded when radical changes to the

health care system are proposed. There is no evidence to support the claim that a repeal of the

Affordable Care Act would benefit low-income populations in any respect. There is evidence to

prove that a repeal or dismantle would have an overall adverse effect on these populations, due to

a decrease in their access to services. Even if not at first, a repeal would eventually result in

higher long-term costs for virtually all parties involved, as well as resulting poorer health

outcomes and life expectancy rates of vulnerable populations. Americans need to analyze new

health care policies that are proposed carefully, utilizing credible sources to help weigh the pros

and cons, and be aware as to how these proposals will affect them personally, as well as their

peers and members of their community. As a nation, Americans must work together to improve

the welfare of all citizens by urging health care policies that accommodate for all.

Works Cited

Affordable Care Act History. Affordable Health California,

affordablehealthca.com/history-affordable-care-act/.

Basu, Rituparna. The Broken State of American Health Insurance Prior to the

Affordable Care Act: A Market Rife with Government Distortion. Pacificresearch.org,

Ayn Rand Institute, www.pacificresearch.org/fileadmin/documents/Studies/PDFs/2013-

2015/BasuF2.pdf.
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Brandon, W. P. "Medicaid Transformed: Why ACA Opponents Should Keep Expanded

Medicaid." Journal of Health Care for the Poor and Underserved, vol. 23 no. 4, 2012.

Project MUSE, doi:10.1353/hpu.2012.0176

Bureau, US Census. Age and Sex of All People, Family Members and Unrelated

Individuals Iterated by Income-to-Poverty Ratio and Race. Census.gov, US Department

of Commerce, 18 Apr. 2015, www.census.gov/search-results.html?q=poverty

%2Bline&search.x=0&search.y=0&search=submit&page=1&stateGeo=none&searchtype

=web&cssp=SERP.

Carroll, Aaron E. A Look at Republican Plans for Repealing and Replacing

Obamacare. The Jama Forum, vol. 317, no. 4, 2017. Jama,

doi:doi:10.1001/jama.2016.19913

Dalen, James E., et al. Why Do So Many Americans Oppose the Affordable Care Act?

The American Journal of Medicine, vol. 128, no. 8, 2015, pp. 807810. PubMed.gov, doi:

0.1016/j.amjmed.2015.01.032.

Eibner, Christine, and Carter C. Price. How Would Eliminating the Individual Mandate

Affect Health Coverage and Premium Costs? RAND Corporation, 15 Feb. 2012,

www.rand.org/pubs/research_briefs/RB9646.html.

Eibner, Christine, and Evan Saltzman. Assessing Alternative Modifications to the Affordable

Care Act: Impact on Individual Market Premiums and Insurance Coverage. Rand Health

Quarterly vol. 4, no. 4, 2015. PubMed.gov,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5158260/.

Federal Poverty Level Guidelines. Obamacare Facts, obamacarefacts.com/federal-

poverty-level/.
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Fox, Jared, and Wanda Barfield. Decreasing Unintended Pregnancy Opportunities

Created by the Affordable Care Act. The Journal of the American Medical Association,

vol. 316, no. 8, 2016, pp. 12. PubMed.gov, doi: 10.1001/jama.2016.8800.

Fryling, Lauren R., Peter Mazanec, and Robert M. Rodriguez. Homeless Persons

Barriers to Acquiring Health Insurance through the Affordable Care Act. The Journal of

emergency medicine, vol. 49, no. 5, 2015. PubMed.gov, https://www-ncbi-nlm-nih-

gov.librarylink.uncc.edu/pubmed/?

term=Homeless+Persons+Barriers+to+Acquiring+Health+Insurance+through+the+Aff

ordable+Care+Act.

Health Coverage Grows Under Affordable Care Act. RAND Corporation, 16 May

2015, www.rand.org/news/press/2015/05/06.html.

Health Insurance Coverage of the Total Population. Health Insurance Coverage of the

Total Population, Kaiser Family Foundation, kff.org/other/state-indicator/total-

population/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location

%22%2C%22sort%22%3A%22asc%22%7D.

Henshaw, Stanley K. Unintended Pregnancy in the United States. Family Planning

Perspectives, vol. 30, no. 1, 1998, pp. 2446. JSTOR, www.jstor.org/stable/2991522.

Hoadley, Jack and Adam Searing. The Ripple Effects of Medicaid Expansion.

Healthaffairs.org, 7 June 2016, healthaffairs.org/blog/2016/06/07/the-ripple-effects-of-

medicaid-expansion/.

Questions and Answers on the Premium Tax Credit. Irs.gov, www.irs.gov/affordable-care-

act/individuals-and-families/questions-and-answers-on-the-premium-tax-credit.
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State Unemployment Rates in 2010 : The Economics Daily. U.S. Bureau of Labor Statistics,

U.S. Bureau of Labor Statistics, www.bls.gov/opub/ted/2011/ted_20110301.htm.

Steinbrook, Robert, et al. JAMA Intern Medicine. JAMA Intern Medicine, 20 Jan. 2017.

PubMed.gov,

jamanetwork.com.librarylink.uncc.edu/journals/jamainternalmedicine/fullarticle/2598796.

Winetrobe, H., et al. Health Insurance Coverage and Healthcare Utilization among Homeless

Young Adults in Venice, CA. Journal of Public Health, vol. 38, no. 1, 2015, pp. 147

155. PubMed.gov, doi:10.1093/pubmed/fdv001.