If the Trump administration has its way, the Affordable Care Act will be gone long before COVID-19. Late last month, the Justice Department laid out its case for declaring the law unconstitutional and striking it down.
That raises the question, what would the COVID-19 pandemic look like in a post-ACA world?
To start, over 20 million Americans who are getting insurance through provisions in the ACA would lose their coverage. Uninsured Americans avoid getting care when they are sick. In the age of COVID, that means their disease doesn’t get diagnosed, and they keep spreading it.
They suffer, and we suffer.
Imagine also that without the ACA, the newly uninsured would include more than 1.1 million people in Texas, 1.9 million in Florida and nearly 600,000 in Arizona — states experiencing record numbers of COVID-19 cases at this very moment. Clearly, some of those who lose coverage would be infected. Some might end up in intensive care units that are filling to bursting. Many of these will receive bills in the hundreds of thousands or millions of dollars that will drive them to bankruptcy, or burden them and their families with debt for decades to come.
Health and finances unprotected
People with health insurance would be in danger, too. Annual and lifetime limits on what insurers will pay would return. And for the many millions who have been infected and survived, any downstream complication of COVID-19 may become a preexisting condition that renders them uninsurable in the future. Why?
Because in the absence of ACA protections, insurance companies will be free, like they were before the law, to refuse to cover conditions that existed before individuals sought coverage.
In the midst of the greatest economic crisis in a generation, hospitals and providers already suffering huge revenue losses will go back to providing care to the uninsured and knowing they will not be paid for it. Their uncompensated care burden could skyrocket 82%. This will further undermine the brave and nimble institutions and professionals who have been incurring huge additional expenses — more ICU beds, more personal protective equipment — and sacrificing lucrative elective procedures to cope with the pandemic.
More health care workers will be laid off, adding to the ranks of the unemployed.
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Rural hospitals will suffer disproportionately, as will those serving the poor and persons of color everywhere. Primary care providers, underpaid and scarce before the pandemic, will face further economic pressure. It will become harder for anyone — regardless of income or insurance status — to find a primary care clinician willing to include them in their practice. This at a time when millions of Americans are eager for advice on what to do when they fear they have been exposed or have COVID-like symptoms, and don’t want to take the risk of going to emergency departments buckling under the burden of the pandemic.
Why not strengthen care instead?
The ACA also made important investments in our public health system, one of our greatest weapons in fighting the pandemic, by increasing vital disease prevention efforts, supporting community health workers and shoring up local public health departments. Even so, public health officials are struggling to get ahead of the pandemic. Now is not the time to reconsider investments in public health.
What would be better for everyone in this country, and our health care system, would be for the administration to drop its support for this lawsuit and work with Congress to make American health care stronger — assuring everyone affordable coverage, protecting our vital hospitals and providers, and ensuring our public health system has everything it needs to combat COVID-19.
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However, if the Trump administration wants to cripple the nation’s ability to fight COVID-19, add to the suffering of the infected and undermine our health care system over the long term, it could hardly pick a better strategy than repealing the Affordable Care Act in the throes of the worst health care crisis the nation has faced since 1918.
Dr. David Blumenthal is president of the Commonwealth Fund. Follow him on Twitter: @DavidBlumenthal