Next month, the U.S. Supreme Court will hear arguments to determine the fate of the Affordable Care Act.
The future of the landmark health care law could become even tenuous with the impending confirmation of Amy Coney Barrett, resulting in an increasingly conservative court. However, if the court hears the case before Barrett is confirmed, she won’t be part of the decision.
A high court decision to overturn or limit the 2010 law, also called Obamacare, will have ripple effects for thousands of Vermonters.
More than 20,000 people who get their insurance on the state health insurance exchange will lose their federal subsidies. Health care will become more expensive for other groups, including people on Medicare.
“It’d be a disaster for the state,” said Mike Fisher, Vermont’s health care advocate. “It’ll be even worse for much of the rest of the country.”
The legal challenge against the Affordable Care Act was brought by 18 predominantly conservative states. They argue that the law’s individual mandate, which requires people to have insurance, is unconstitutional.
Because the mandate is inseparable from the rest of the law, the whole ACA should be thrown out, the states argued in the suit.
Seventeen states, including Vermont, have signed on to defend the law. The court is expected to issue its ruling before its term ends next June.
The specific impact to Vermont remains up in the air. Before the Affordable Care Act, Vermont and a handful of other states received waivers to expand Medicaid coverage, including raising the income for people who qualify to 138% of the poverty line.
Those waivers were nullified by the ACA, and expired. Whether and when the federal government would be willing to replace those waivers is unclear. “We’d have to redo some things that had been done before,” said Ena Backus, director of health care reform for the state.
•••
Here’s what we know about the impacts of a decision
Thousands would lose government subsidies.
About 22,000 Vermonters who get their insurance on the state exchange, Vermont Health Connect, will lose federal subsidies. Those are people who don’t get insurance through their work — small business owners or freelancers, part-time or hourly employees, typically people between ages 18 and 65.
In 2020, that group is expected to receive a total of $114 million in subsidies from the federal government, reducing the cost of their insurance, according to data from the Department of Vermont Health Access.
If the ACA were overturned, those people would lose that money — or the state would have to pick up the tab.
People on Medicare will pay more for care.
Repealing the Affordable Care Act will also be costly for Vermonters on Medicare, the national health insurance program for older Americans that was established in 1966. The ACA increased payments to doctors and hospitals under Medicare; overturning the law would raise prices for Medicare beneficiaries in co-pays and deductibles, according to an analysis by Kaiser Family Foundation. People will pay more for prescription drugs and face costs for preventive care, such as primary care checkups or diabetes checks, which are now free. How much, exactly, remains to be seen.
Vermonters are better off than people in other states.
In 2019, the Vermont Legislature passed a law to continue Obamacare protections for some of the state’s residents.
The law, H.524, extends protections for people with pre-existing medical conditions. That population will likely increase, as people develop long-term impacts of Covid-19. It already could include as many as half the people under age 65, according to a 2017 government analysis.
The law also bans insurance companies from setting limits on how much they’ll cover per person, either annually or over the course of a lifetime. The Vermont legislation also allows adult children to stay on their parents’ health insurance up to age 26, continuing the protections under the ACA.
The outlook is much worse nationally. More than 20 million Americans could lose their health coverage. As many as 133 million people with pre-existing conditions could be forced off their insurance or forced to pay much more for it. About 12 million low-income Americans could be kicked off the Medicaid rolls, according to The New York Times.
“The Vermont Legislature did a really good job anticipating that potential safeguards were in place in Vermont,” Backus said.
Questions remain about other discounts.
As part of a cost-sharing reduction program, Vermonters who earn up to 300% of the poverty line and get a silver plan on the state exchange can receive help on out-of-pocket health expenses, such as co-pays. It’s unclear whether that would remain the case after a court ruling, said Nissa James, spokesperson for the Department of Vermont Health Access.
Calorie counts, and other impacts
The Affordable Care Act requires calorie counts on menus at chain restaurants — that requirement would go away if the law were overturned.
The ACA also seeks to increase the number of doctors, nurses, dentists, therapists, and other medical professionals. Training programs that help remedy the shortage of clinicians could be at risk.
In addition, the law mandates shared costs between insurance companies. A Supreme Court decision would increase the imbalance between MVP Health Care, which has healthier patients, and Blue Cross Blue Shield, which bears higher costs for its sicker patients.
It likely won’t affect Vermont’s health care reform efforts.
Vermont rolled out the all-payer model in late 2016, which is based on agreements between the state and the federal government.
The health care reform changes the way hospitals are funded, paying them per patient rather than for each procedure. A repeal of the ACA would be “a disaster” for Vermont, but it wouldn’t have an effect on the all-payer effort, said Susan Barrett, executive director of the Green Mountain Care Board.
The details, of course, remain to be seen. “But those are the tea leaves we’re reading,” Barrett said.