5 Things That Would Be Impacted If the ACA Is Overturned

Earlier this week, a federal appeals panel heard arguments over the constitutionality of the individual mandate and the Affordable Care Act (ACA) as a whole. As the fate of the ACA remains uncertain, 21 million people are at risk of losing their health insurance. In addition to large coverage gains as a result of the ACA, the law resulted in various other sweeping changes to the US healthcare system. Here are 5 things that would be impacted if the ACA is overturned:

1. Pre-existing conditions

One of the most significant changes made by the ACA was the law’s protections for the 133 million Americans with pre-existing conditions. The protections have remained popular among voters, with large majorities reporting that it is “very important” to keep the provisions that prevent insurance companies from denying coverage based on a person’s medical history and from charging sick people more. Approximately 40% of voters also reported being “very worried” that they or a family member will lose coverage if the ACA is overturned.

The Trump administration has voiced commitment to protecting people with pre-existing conditions; however, stakeholders and organizations are skeptical over these claims, citing the administration’s advancement of a health insurance option that is not required to include such protections.

2. Medicaid expansion

In addition to increasing coverage rates, the Medicaid expansion authorized under the ACA has reaped various benefits, including earlier cancer diagnoses, lower maternal mortality rates, and fewer cardiovascular deaths. Since the law expanded access to Medicaid for people with incomes up to 138% of the federal poverty level, 33 states and Washington, DC, have implemented Medicaid expansion and another 3 states have adopted expansion and are waiting for implementation.

Repealing Medicaid expansion has the potential to reverse these improvements in quality and service use that have been gained over the last decade, and research has shown that low-income rural populations would be hit particularly hard.

3. Medicare experiments

As the US health system continues to strive for value-based care, the Center for Medicare and Medicaid Innovation (CMMI) created under the ACA has played an integral role in the shift from volume to value by allowing testing of innovative payment and delivery models. Most recently, the administration introduced 5 new payment models to transform kidney disease care and a mandatory bundled payment model for radiation oncology.

One of the most broadly implemented initiatives under CMMI is the formation of accountable care organizations in Medicare, and the administration has been pushing for the International Pricing Index, which would allow Medicare to determine the price that it pays for certain drugs based on the prices that other countries pay.

When asked what would happen to proposals like these if the ACA is struck down, CMS Administrator Seema Verma indicated that the agency has a plan in place and that “the idea here is to keep what’s working.”

4. Young adult coverage

Rolling back the ACA would mean that approximately 2 million young adults could no longer stay on their parents’ insurance until age 26. Prior to the ACA, once a young adult turned 19 years old or was no longer a full-time student, they were responsible for obtaining their own coverage. In 2009, just 43.7% of all people aged 18 to 24 years and 55% of people aged 25 to 34 years were covered by an employer-sponsored plan.

During the presidential election, voters across party lines reported being in favor of allowing young adults under age 26 to stay on their patients’ insurance, with 59% of voters being very favorable of the provision and 27% being somewhat favorable.

5. Biosimilars

With biosimilars making a presence in the European Union, the ACA implemented the Biologics Price Competition and Innovation Act (BPCIA), which enabled the FDA to create a biosimilar approval pathway. Since then, there have been 21 approved biosimilars, 7 of which have entered the market. The pace of approvals has accelerated since the first indication for a filgrastim biosimilar in 2015, increasing to 3 approvals in 2016, 5 in 2017, 7 in 2018, and 5 so far in 2019.

It’s estimated that the annual savings to the US health system could amount to $60 billion in 2023, creating a 5-year savings of $153 billion. However, overturning the ACA could jeopardize these projected savings and the growing pipeline by discouraging drug makers from investing in new biosimilars.

Ha Kung Wong, JD, a partner at Venble LLP, told The American Journal of Managed Care^®’s sister site The Center for Biosimilars^® in an email that “the BPCIA biosimilars pathway would essentially cease to exist and need to be passed by Congress all over again.”