Healthcare—a look back at 2020 and moving forward

Through much of a tumultuous 2020, as the pandemic raged in fits and starts, our GOP-controlled government continued to pursue “trashing” the ACA and ignored proposed legislation at both the state and federal levels that would help people afford healthcare insurance and the care they need.

On Nov. 10, only days after Ruth Bader Ginsberg’s death and the GOP rushed through Trump’s third appointment to the Supreme Court, Amy Coney Barrett, the first Supreme Court hearing on the multi-Red-state case against the ACA took place. At this hearing, the “liberal” wing (Breyer, Sotomayor, and Kagan) was joined by Kavanaugh and Chief Justice Roberts in agreeing that to kill the entire healthcare act because of one easily severable law, the “Individual Mandate,” did not make sense. Once thought to have been a key to getting people to sign up, the modest annual penalty for not having ACA-compliant health insurance had not made much of a difference in ACA enrollments. In fact, Republicans had cut the penalty to zero, which basically did away with it. So, if Congress were to sever the pesky individual mandate, the ACA could prevail, continuing to insure more than 23 million people. Conservative Justices Thomas, Alito, and Gorsuch still wanted to strike down the entire healthcare act. Justice Barrett was “harder to read,” but even if she ended up agreeing to take down the ACA, the vote would be 5 Justices for the ACA and 3 or 4 against it. Hearings will continue beginning in June or July, but the prospects for a favorable outcome for the ACA look good.

How effective has the ACA been as a safety net during the pandemic?

In spite of the Trump Administration’s slashing the advertising budget and the enrollment period, and refusing to create new signup periods during a pandemic, enrollments in both the ACA marketplace exchanges and Medicaid have grown. Because of the fluid situation of job losses (temporary versus permanent, and partial job losses and recovery), enrollment numbers in the marketplace are not easy to track, especially in recent months. Still, we do have some figures.

Likely fueled by job losses during the pandemic, 2020 was the only year during the Trump administration when ACA enrollments went up. Signups for marketplace plans run by healthcare.gov increased by 6.6 percent in 2020 compared with 2019 (New York Times “Upshot”). Preliminary enrollment numbers released by federal officials in December suggest that more people bought coverage for 2021 through the ACA marketplaces than they did in 2020, even in the absence of enrollment encouragement from the federal government and fears that the ACA would be destroyed (Kaiser Health News).

States that have created their own marketplace exchanges on the ACA are free to create and expand their enrollment periods and make other modifications that could help enroll many more people. PENNIE, Pennsylvania’s new ACA exchange, had a smooth roll out during its first enrollment period (ending December 15, 2020)..

Given the pandemic, PENNIE expanded its enrollment period for 2021 until January 15 (for coverage beginning in February). Final enrollment figures are not expected until March. Negotiations with insurance companies apparently had mixed results, with premium prices down, but not across the board, leading to some affordability problems (Pennsylvania Health Access Network). And there are subsidies for qualifying people. Some people who had lost a job and enrolled in Medicaid may apply to PENNIE once they secure employment again. This is good news.

Medicaid and expansions

One of the great successes of the ACA has been the Medicaid expansions, designed for low-income people who are not eligible (in terms of affordability) for the ACA or for traditional Medicaid due to its requirements. To date, 39 states, including Pennsylvania, have adopted a Medicaid expansion and together have enrolled more than 15 million individuals (Kaiser Family Foundation). These expansions saw an enrollment growth rate of 22.2 percent between February and November. In contrast, nearly 3 million low-income people were ineligible for assistance in the states that declined to expand Medicaid under the ACA. These states include Texas, Florida and other Red states mostly in the South, where coronavirus cases are now spiking.

In its December analysis of insurance industry data, Kaiser Family Foundation researchers found that roughly 2 to 3 million Americans lost their job-based health coverage between March and September. During the same period, around five million people enrolled in Medicaid.

As the pandemic worsens, millions more people are out of work and eligible for Medicaid. This growing need, however, coincides with major state budget shortfalls due to plunging revenues created by the pandemic economy. The first COVID-Relief Bill (the CARES Act) provided for a 6.2 percentage-point increase in the federal medical assistance percentage, or FMAP — the share of Medicaid costs that the federal government pays to each state. For months, Democrats in Congress urged that a similar amount to be sent to the states as part as the next relief bill. Without adequate federal aid, many states would be forced to cut Medicaid and other healthcare programs, jeopardizing coverage and access to care in the midst of a public health crisis. Finally, in late December, Congress conceded, adding to the second COVID-Relief package $100 billion in state aid that can be used to “backfill” state revenue losses, if needed. There’s no guarantee, however, that states will then use this new money in their budgets to shore up Medicaid.

In conclusion, ACA and Medicaid have been a helpful safety net for many people in 2020. Still, millions are uninsured. This is partly explained by so many people struggling just to put food on the table or pay their rent. Applying for healthcare insurance is the last thing on their mind, especially in our overly complicated healthcare system. If our country had universal healthcare, with everyone automatically covered, the situation would be quite different.

The bright spot is the election of Joe Biden and Kamala Harris, who are determined to shore up and improve the ACA, including adding a “public option.” But even with somewhat fragile Democratic control of both branches of Congress, this won’t be easy. Trump and his party have created so many crises needing attention ASAP, that improvements to our healthcare system will take time.

Jeanne Duffy, Ph.D., has served as a college professor, an analyst and project manager for several large companies, and a college administrator in charge of foundation and government support. She is Chair of Gettysburg Democracy for America’s healthcare taskforce.