Since its inception ten years ago, the Affordable Care Act (ACA) has extended health care coverage to tens of millions of previously uninsured Americans. Yet, as a result of the Covid-19 pandemic, millions of people have lost their jobs and employer-sponsored health insurance. The Trump administration has decided not to mandate a special ACA enrollment period, while many state governments face severe shortages in funding that would enable them to increase Medicaid coverage.
We asked faculty expert Heather Howard, lecturer in public affairs at Princeton University’s Woodrow Wilson School of Public and International Affairs, to share her thoughts on the ACA’s future, given the upcoming U.S. Supreme Court litigation; how states have mobilized to fill in the gaps during the pandemic; and the implications of the $175 billion Provider Relief Fund created by Congress.
Howard is serving on the Health Care Subcommittee of New Jersey Governor Phil Murphy's Restart and Recovery Advisory Council. She is director of the State Health and Value Strategies Program (SHVS), based within the Center for Health and Wellbeing, and previously served as New Jersey's commissioner of health and senior services.
Q. The ACA turned 10 recently, yet it is still being litigated in the courts, with the U.S. Supreme Court agreeing to hear the case involving Republican state attorneys general challenging the constitutionality of the law. What do you see ahead for the ACA?
Howard: The ACA has proven surprisingly resilient, even in the face of political, operational, and legal challenges. To date, the law has survived not only two Supreme Court challenges but also an all-out repeal effort by the Trump administration and Congress that initially seemed to be a foregone conclusion after the 2016 elections. Even now, the ACA faces yet another existential threat, with the Supreme Court taking up the appeal in a case brought by Republican state attorneys general challenging the constitutionality of the law after the individual mandate provision was effectively eliminated by Congress. This case could jeopardize the entire law, including coverage for more than 20 million people and consumer protections — such as preexisting condition protections — for many millions more, potentially throwing the health care system into chaos. Arguments have not yet been scheduled and could fall before the 2020 election; even if the case is heard after the election, the challenge to the law will certainly be an issue in the presidential election.
Q. Millions of people living in the U.S. have lost their jobs, and President Trump has refused to re-open the ACA marketplaces so these individuals can purchase health insurance. What are the implications of this?
Howard: We know that economic downturns lead to higher rates of “uninsurance,” as many people lose their health insurance coverage when they lose their jobs. It’s unfortunate that the administration has not created a special enrollment period for people to purchase health insurance in the ACA marketplaces, but the good news is that almost all state-based marketplaces — with the exception of Idaho — opened special enrollment periods to allow uninsured residents to enroll in coverage, and we are seeing tens of thousands of individuals taking advantage of those opportunities. In addition, several governors whose states rely on the federal health care platform are asking the administration to reconsider its decision. And finally, in addition to ACA marketplace coverage, many people who lose their jobs may qualify for Medicaid, and states have been spreading the word about this coverage option.
Q. You are the program director of the State Health and Value Strategies program. What are some of the top resources and strategies states have at their disposal for responding to the pandemic?
Howard: We have created a one-stop resource page for states with information and tools for states seeking to make coverage and essential services readily available to their residents. Responding to and slowing the spread of the Covid-19 pandemic is front and center for all states, with many governors focused on promoting access to and expanding coverage for Covid-related testing and treatment. These strategies include waiving cost-sharing requirements, extending grace periods for paying for health insurance, and creating special enrollment periods for individuals to obtain health insurance coverage. In addition to promoting coverage options, many states also are relaxing regulatory restrictions to support and expand workforce capacity, including expanding telehealth, temporarily granting licenses to out-of-state providers to practice in-state, temporarily easing licensing restrictions for foreign-educated doctors, and easing practice restrictions on other providers like advanced practice nurses and physicians assistants.
Q. How can the federal government better assist states? Are you seeing actions within individual states that you believe could help inform improved health policy at the federal level?
Howard: States often have led the way on health policy, and that’s been certainly been true in the response to Covid-19. But the pandemic has placed unprecedented burdens on state health programs and those stresses are compounded by the economic downturn, which will starve state budgets when states need resources the most. So, the most helpful assistance the federal government can provide states as this point may be financial. Indeed, additional direct aid to states and municipalities (which all face balanced budget requirements that do not constrain the federal government) is currently under debate in Congress.
Q. How will the funding the U.S. Congress earmarked for health care providers be distributed?
Howard: Congress created and allocated $175 billion to a Provider Relief Fund, to reimburse health care providers for expenses and lost revenues attributable to Covid-19. This was in recognition of how the pandemic has dramatically changed health care utilization – from the cancellation of elective procedures to patients deferring care to avoid exposure, declining utilization is severely threatening the financial solvency of many health care providers. The first tranche of funds has been distributed based on net revenue for Medicare providers. This focus on providers serving Medicare patients means that providers predominantly serving Medicaid and uninsured patients, including behavioral health and obstetric and pediatric providers, received less or no support and are at greater financial risk during this crisis. Going forward, I expect there will be more attention focused on the need to support these safety net providers.
Q. You teach an undergraduate seminar on U.S. Health Reform. How are you incorporating the current crisis into the curriculum?
Howard: The course focuses on the Affordable Care Act — its origins, implementation challenges, and uncertain future — as a lens for understanding the American health care system. We naturally turned to examining the Covid-19 crisis as it unfolded, exploring the policy issues related to testing and treatment, applying our new understanding of the federalism challenges and opportunities in our health care system, and debating the cracks in our health care system exposed by the crisis. As we moved to virtual learning and Zoom classes, I used breakout rooms to allow students the space in small groups to debate in real time some of the cutting-edge questions being surfaced by the crisis. For example, one week early in the pandemic the students discussed whether they would advise Florida Governor Ron DeSantis to close the state’s beaches, and in another class we brainstormed proposals for a “Public Health New Deal” to strengthen our health care system going forward.
WWS Reacts is a news-focused series featuring faculty who present their views on current events.