Susan BornsteinWere you born female? If so, are you at risk of pregnancy? Do you want to conceive, or alternatively, do you need birth control? Do you want coverage for well woman exams, mammograms? Were you born male? Are you either employed or unemployed, but do not qualify for Medicare or Medicaid? Are you a 23 year old newly minted college graduate looking to establish your career, but not yet on solid financial footing? Gender aside, do you have any underlying health problems? Do you need a colonoscopy? Maybe you have depression, or anxiety? If so, you benefit from the protections established in the Affordable Care Act.
One of the largest obstacles confronted by anyone who needed to purchase health insurance prior to the implementation of the ACA was that unless you were a healthy young man, the premiums were high. There was no set of standard benefits associated with various insurance policies. Not only that, but there was a reasonable chance that if you had any underlying health issues, known in healthcare parlance as “pre-existing conditions,” such as hypertension, diabetes, or, heaven forbid, cancer, even if they had resolved, or prior surgeries, that if you could even find an insurance company which would sell you a policy, the rates were unacceptably high. About 20% of the time, you could not purchase insurance at all. This produced high costs from emergency utilization of medical services, not to mention worse outcomes from delayed care. According to a 2018 study, 2/3 of bankruptcies are a result of healthcare costs or time off work due to medical illness. (Himmelstein DU et al., 2019) Unpaid bills also strain the resources of medical providers and hospitals, since they have an uncompensated cost associated with providing services received. Since passage of the ACA, the number of uninsured Americans decreased from 46.5 million in 2010 to under 27 million in 2016. Although the number of uninsured has risen some since then (to 33 million in 2019), a situation worsened by the rise in unemployment secondary to the Covid epidemic, the number of uninsured persons remains significantly lower than the pre-ACA state.
Did you realize that The ACA requires that insurers cover well woman care? This means pap smears to screen for cervical pre-cancerous and cancerous lesions, mammograms, screening for domestic violence, contraceptive counseling, the chance to talk about wearing seatbelts, assessing for fall risks, finding and discussing unusual weight loss or weight gain, talking about exercise, how to increase the chances of staying healthy, how to reduce stress in the time of Covid. It can mean a routine exam that discovers a cancerous thyroid nodule or rectal cancer, as my patients can attest. I detected overactive and underactive thyroid disease affecting quality of life and breast cancer not seen on radiologic screening, but picked up on clinical exam. An annual exam is an opportunity to ask a question about something that is bothering you, and receive a reassuring response-no, you don’t have to worry, it’s nothing. Other times, the question may lead to further investigation, uncovering a problem we can treat, leading to a better and longer life. Do we want to relinquish this? Don’t we deserve to have it?
Another provision of the ACA requires insurance companied to cover maternity care. Uninsured women are more likely to receive less care, have worse pregnancy outcomes, and their newborns are more likely to be of low birth weight and are more likely to die. This makes sense. If you aren’t able to see the doctor during pregnancy, or to be seen regularly, the odds are much greater that your gestational diabetes, high blood pressure, or bladder infection will not be diagnosed, to the detriment of you and your baby. If you aren’t checked, it is not possible to monitor your baby’s growth, or screen for anemia. Missed visits are missed opportunities to make sure that you are safe in your home, that you have adequate social support, that you have what you need to care for yourself and your child. All moms, both new and experienced, have questions and concerns. If you cannot access care, your worries fester. Anxiety isn’t good for you or your baby. Health insurance is vital for pregnant women and their newborns.
The Affordable Care Act mandates that insurance companies cover all FDA approved contraceptives. While there were already religious exemptions to this rule, unfortunately for women and their families, this imperative was further compromised by a 2017 presidential executive order, which allows any employer who does not wish to provide contraceptive coverage to be exempt from doing so. Access to affordable contraception is key to allowing women to build their lives and their families on THEIR timetable, when they feel emotionally and financially ready. Decreasing access to contraception is counter-intuitive to the desire to reduce the number of unplanned pregnancies and abortions. Does anyone think that birth control is “worse” than abortion? Since sex can produce unwanted pregnancies, which can lead to abortions, it stands to reason that the way to reduce the number of abortions is to make contraception easy to access, safe, and cheap.
The goal of all the parents I know is to raise healthy, happy children who ultimately leave the nest and have fulfilling, independent lives. Nowadays, especially with the Covid-related downturn in the economy, it is hard to find a job, with or without a college degree. Many starter jobs have low wages, or may not provide insurance benefits. The ACA allows children up to age 26 to remain on their parents’ health insurance. Knowing that you are protected from catastrophic financial debt in the event of a major illness or accident is one less thing to worry about.
Let’s talk about mental health. We all want it, and the Covid pandemic is challenging our ability to hold on to it. Most of us, at some point in our lives (maybe all of us at the moment!), would benefit from counseling. We might also need medication for anxiety, depression, bipolar disorder, or other mental health diagnosis. The ACA adds to previous mental health coverage regulations by requiring that, similar to previous regulations governing large group health plans, small and individual group plans, as well as Medicaid expansion plans, must cover mental health services at the same level that they cover medical and surgical services. Or, we may feel fine now, and can’t imagine that we’ll ever need mental health coverage. However, life has a funny way of changing our expectations-an unexpected loss of a loved one, divorce, serious illness. None of us are immune to tragedy and sickness. Having ready and affordable access to professional mental health experts can have a profound effect on the quality and quantity of our days.
Prior to the ACA, insurance underwriters could charge more for females than males, older compared to younger patients, and sicker vs healthier patients. This was all well and good if you were a 26 year old healthy male with a desk job, but not so great if you were a 40 year old diabetic woman working on an oil rig. The ACA eliminates premium cost discrimination based on gender and pre-existing conditions, and limits the amount that older patients can be charged relative to younger patients to a 3:1 ratio. Yes, it makes premiums higher for younger males than they would have been before, but this at least theoretically makes it possible for older, sicker people to be able to obtain and afford insurance. The effectiveness of this cost control measure was undermined by loss of the individual mandate, which required everyone to have insurance or pay a penalty, as well as by the approval of low cost, low benefit non-ACA compliant plans. The net effect was to take younger, healthier people out of the marketplace, and drive up rates for the remainder. (Insurance works by having low risk enrollees offset the risks of high risk enrollees. If everyone who had fire insurance had their house burn down, the homeowners’ insurance companies would quickly go under).
Is the ACA perfect? Not by a long shot. In Kentucky, where I live, there are only 2 insurers selling individual policies on the exchange. To purchase a Silver plan for my husband and myself will cost $1800/month in premiums, with a $13,600 deductible, and out of pocket maximum of $14,600. Therefore, the total exposure every year is over $36,000. And there are no alternatives for individual coverage other than the exchange. However, without the ACA protections, we might not be able to buy health insurance at all, also an unacceptable option. The best solution? The US must join all the other developed countries around the globe and institute a universal health plan. Do not make health insurance dependent on employment. Make healthcare affordable and accessible for everyone. It should be the American way. We can do this.
Himmelstein DU, Lawless RM, Thorne D, Foohey P, & Woolhandler S. (2019). Medical Bankruptcy: Still Common Despite the Affordable Care Act. American Journal of Public Health, 109(3), 431–433. https://doi.org/10.2105/AJPH.2018.304901