Health

4 HE ALTH • Spring 2021 T he Affordable Care Act survived the Trump Administration. Now the vice president who helped get the act passed in 2010 is growing it to provide coverage of more Americans. President Joe Biden is already off to a good start in expanding some elements of the program – one of his top campaign goals. Biden's upgrades to the ACA highlight a year or more of proposed federal and state legislative measures, changing the way health care is provided for and delivered. On the state level, new laws are being contemplated for aid in dying, telehealth, behavioral health, and vaccine mandates. A $1.9-trillion pandemic relief bill, the American Rescue Plan, included lowered monthly payments for a broader segment of families and new incentives for states that haven't expanded Medicaid already – namely Florida and Texas – to do so now without as many additional costs. Those expansions were put in place only through 2022, leaving its longer- term shape more open-ended. But it nonetheless makes important strides toward making the ACA more affordable in two important ways, said Megan Cole, a Boston University School of Public Health professor. First, the expansion will help middle-class families find affordable coverage by removing an income cap on premium subsidies, with anyone enrolling paying no more than 8.5% of their income, she said. It'll give more generous subsidies to lower-income families who qualify for plans with no premiums, and for a broader segment of households to purchase better- quality plans with smaller deductibles. Those expansions are estimated to insure 1.3 million people for the first time at a cost of $34 billion, according to the Congressional Budget Office. The ACA, more than a decade after its passage, already made a significant dent in the number of Americans without health insurance. From more than 15% who were uninsured then, the rate is now 9% as of 2019, according to the Kaiser Family Foundation. Massachusetts leads the nation in health coverage, with only 3% of the population uninsured, according to Kaiser. That can mask how much of the rest of the country remains uncovered: 9.2% nationally and far more in some of the nation's most populous states, including 18.4% in Texas and 13.1% in Florida. "We'll have to see how many [states] take advantage," Cole said. A report in January by the nonprofit Urban Institute in Washington, D.C. explained in part why: an estimated 47% of uninsured adults said in a survey they hadn't looked for information on potential coverage or tried obtaining it. Most of those who didn't try didn't think they'd qualify, the report said. Obamacare survives a major challenge Experts on federal health policy portrayed the ACA as having made it through Donald Trump's four years as U.S. president despite his efforts to first overturn it through both legislative and judicial efforts, and later by weakening it by ending marketing efforts and assistance grants. "It's clear that essentially from every angle they could, the Trump Administration was trying to take apart the ACA," said Paul Shafer, a Boston University School of Public Health professor. "There was no appetite to go back and fix things that weren't working as well," said Amy Lischko, a professor at the Tufts University School of Medicine in Boston. Instead, she said, Trump and Republicans attempted to repeal the plan or have it deemed unconstitutional without efforts to strengthen it. Cole said she sees other areas where important improvements could still be made to the ACA, including extending the period of time for women to receive Medicaid coverage postpartum, which now ends after 60 days. Shafer also believes that period should be lengthened. "Complications can lead to increased risk of death for up to year after delivery," he said, "so this was a long A number of federal and state public policy measures seek to overhaul health care for the foreseeable future Legislating health care Where law Where legislation is has passed being considered California Arizona Colorado Indiana Hawaii Iowa Maine Kentucky Montana Massachusetts New Jersey Nebraska Oregon New Mexico Vermont New York Washington North Dakota Rhode Island Where aid in dying is legal Massachusetts would be the 10th state to pass a law allowing terminally ill patients to end their life with the help of a physician. It's one of 10 more states considering such a law. Source: Compassion & Choices • By Grant Welker House Speaker Nancy Pelosi and Senate Majority Leader Chuck Schumer sign the American Rescue Plan Act on March 10, which includes new expansions of the Affordable Care Act. PHOTO/COURTESY OF SENATE DEMOCRATS

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