What Happens if SCOTUS Overturns ACA, Besides Coverage Loss?

Update 11/5/2020: This article has been corrected to state that the Supreme Court will hear the oral arguments regarding the Affordable Care Act’s constitutionality on November 10, 2020. A previous version incorrectly stated that the decision will be released on November 10, 2020. Kaiser Family Foundation has noted that the Supreme Court may not release its final decision until June 2021.

With the Supreme Court preparing to hear the oral arguments regarding the Affordable Care Act’s constitutionality on November 10, researchers from the Robert Wood Johnson Foundation and Urban Institute have published a list of potential impacts of an Affordable Care Act overturn, going beyond the initial coverage losses.

“If the ACA is overturned, the consequences will be devastating for millions of Americans,” the brief began. “Some of the most popular ACA provisions, including protections for people with preexisting conditions and the extension of dependent coverage to young adults up to age 26, would be eliminated.”

The first implication that may come to mind would be the impacts on health insurance status and the uninsured rate.

In the vacuum left by the overturned Affordable Care Act, around 20 million Americans might lose their healthcare coverage and the rate of uncompensated care could skyrocket. Under 2019 conditions, the number of uninsured would grow to 50 million, particularly impacting healthcare coverage for minority communities.

Losses may be centralized among people of color, those without a college education, and younger adults.

Without the Affordable Care Act, young adults between 19 and 25—an age group highly susceptible to uninsurance—may no longer be able to receive dependent coverage on their parents’ health plans. The uninsurance rate for Hispanic and nonwhite adults without a college education dropped 13.5 percentage points in the first four years after the law’s passage.

“The populations gaining the most coverage because of the ACA will likely experience the greatest increases in uninsurance if it is overturned,” the researchers predicted.

Coverage loss is where an unfavorable ruling on the Affordable Care Act’s constitutionality would be most obvious, but it is not the only devastating impact.

Costs on the individual insurance market will rise because the federal government will no longer be subsidizing health plans for lower income individuals, making it difficult for individuals to access affordable coverage.

Additionally, those who have pre-existing conditions may be denied coverage on the individual health insurance market. The law has this power not merely based on a statement that health plans cannot discriminate, but because of specific provisions that protect individuals against discrimination before they apply for coverage and while the health plan serves them.

“The ACA has several provisions that make individually purchased insurance coverage more accessible and affordable for people with health problems, including guaranteed issue of all products, modified community rating, essential health benefits requirements, and cost-sharing limits,” the researchers explained. “Without these combined measures in place, any promise to protect people with preexisting conditions would be unable to ensure access to adequate and affordable coverage.”

Affordability is not the sole goal of healthcare coverage. Comprehensiveness is also important. Under the Affordable Care Act, plans on the individual insurance market are required to cover essential health benefits. Without this law, that level of comprehensive coverage could be in jeopardy, the researchers indicated.

Also, more patients may defer or delay care due to cost.

Medicaid expansion and marketplace subsidies made normal healthcare needs more affordable for patients, encouraging them to be more proactive in their own healthcare, the researchers asserted. Between 2013 and 2017, adults who had a routine check-up increased, they added, and the ability to afford care rose under the Affordable Care Act.

The inability to meet the costs of necessary healthcare could drive low income individuals into medical debt. Hospitals would also struggle with financial stress, as they see more uncompensated care and lose Medicaid revenues.

The nation has made great gains in women’s healthcare under the Affordable Care Act which could be lost in the case of an overturn. Women’s uninsurance dropping 9.8 percentage points between 2010 and 2016. Women younger than 35 years old, Black and Hispanic women, and single mothers saw the greatest progress in coverage.

Some experts consider it highly unlikely that the Affordable Care Act would be overturned. And it is important to note that even if the Affordable Care Act is ruled unconstitutional, these impacts would not necessarily take effect the instant that the Supreme Court hands down the verdict.

If the Affordable Care Act was ruled unconstitutional, it would set off a chain of events in the political and legal spheres that are hard to predict in advance. Very likely, Congress and the Administration would take steps shortly after the decision to try to stabilize the situation.

The Trump Administration indicated its strategy—with or without the Affordable Care Act—through a recent executive order announcing the America First Healthcare Plan.

The president said the plans’ goals were to increase patients’ choice of health plans, lower healthcare costs, and better quality of care. The plan emphasized short-term and association health plans and health reimbursement arrangements to provide more choice. It pushed price transparency to bring down healthcare prices and would tie drug prices to international rates.

However, experts have retorted that this order has no teeth and is simply a statement of intent, not a directive.