The battles over the health law have played out during a decade of continuous economic growth. How it performs as a safety net now may help determine its future.
The Affordable Care Act, the landmark health law that has been a subject of caustic debate for more than a decade, is being tested as never before, as millions of Americans lose their jobs and medical coverage in the midst of the nation’s gravest health crisis in a century.
The law is offering a vast majority of newly unemployed people a path to stopgap health coverage, providing a cushion that did not exist during the last crushing recession — or ever before. But the crisis has also highlighted fundamental weaknesses with its patchwork system — ones magnified by Republican efforts to undermine and dismantle it, but also seized on by some Democrats pushing for a sweeping overhaul.
On Thursday, as the coronavirus pandemic surged and the country reported a daily record in new virus cases, the Trump administration continued the Republican Party’s push to abolish the law. Shortly before midnight, the Justice Department filed a brief asking the Supreme Court to overturn the law, in a case brought by a group of Republican attorneys general.
The case is likely to be argued this fall during the closing stages of a bitter presidential election in which health care is certain to be a galvanizing issue. Joseph R. Biden Jr., the presumptive Democratic nominee, continues to support improving and expanding the A.C.A. with an option to buy a public plan, rather than replacing it with a “Medicare for all” system preferred by many in the left wing of the party.
As those political and legal battles play out, how the law actually works in the coming months of intense need could go a long way toward determining its durability and future.
“This is the first test of the A.C.A. in an economic downturn,” said Peter V. Lee, the executive director of Covered California, the state’s insurance marketplace created under the law. “But it’s not just a test — it’s a national study of what happens in states that implemented the A.C.A. as opposed to those that didn’t.”
Four out of every five people who have lost employer-provided health insurance during the coronavirus pandemic are eligible for free coverage through expanded Medicaid programs or government-subsidized private insurance, according to the Kaiser Family Foundation, a nonpartisan health research group. And many jobless 20-somethings have been able to join their parents’ plans. All three options were made possible by the law.
Yet others have fallen through the holes in the law’s safety net. Nearly three millionlow-income people are ineligible for assistance in the 14 states that have declined to expand Medicaid under the law, including Texas, Florida and others, mostly in the South, where coronavirus cases are now spiking. Many people who have qualified for government subsidies to buy private plans still face unaffordable co-pays and deductibles.
David Exum, of Kannapolis, N.C., has experienced both the benefits and the shortcomings of the law. He lost his health coverage when he was laid off from his job as a web content coordinator in March. He is now paying just $1 a month for a subsidized plan.
It is a big improvement from the last recession, he said, when he became uninsured for several years after losing his job and getting divorced. But for Mr. Exum, 53, the law is imperfect.
His plan is cheap because it has a high deductible — $6,900 a year. Worse, if his unemployment benefits expire before he finds a new job, and his income drops below the poverty line, he will lose his premium subsidies and will no longer be able to afford the plan. But because of a quirk in the law, he would not be eligible for Medicaid in that situation, because North Carolina has not expanded the program to cover many low-income men.
“I know there are millions in the same boat,” said Mr. Exum, who has been walking a mile or two a day to stay healthy during the pandemic. “It’s just really scary.”
The strange glitch exists because the law originally required all states to expand Medicaid, and thus did not set up a system of subsidies for the poorest Americans to buy private coverage. The Supreme Court ultimately ruled that states could opt out of expanding Medicaid, but Congress, bitterly divided over the law, never fixed the glitch.
“The pandemic has exposed some of the glaring weaknesses in the A.C.A.,” said Paul Starr, a professor of sociology and public affairs at Princeton who served as a health policy adviser to the Clinton administration. “When millions of workers lose their jobs, most of them also lose their health coverage, and the A.C.A. does not provide for any automatic backup or means of transferring coverage to a publicly subsidized alternative.”
“To be sure, we are better off with the A.C.A. than without it,” Mr. Starr added, “but we ought to be prepared to go beyond it and create a system that doesn’t leave so many Americans in the lurch.”
The A.C.A. brought the country’s uninsured rate down to record lows several years after it was enacted in 2010, but even before the pandemic some 28 million people had no coverage. Still, an analysis by the Kaiser Family Foundation estimated that 27 million Americans could have lost job-based health coverage between March and May, and that a vast majority of them — 79 percent — are eligible for new coverage from Medicaid or subsidized private plans.
In the 36 states that expanded Medicaid, the Kaiser analysis predicted that 14 million people would qualify for the free program and another 3.5 million would qualify for subsidized A.C.A. plans.
Some states are already seeing spikes in Medicaid enrollment — in May alone, enrollment jumped by 8.4 percent in Minnesota and by 8.2 percent in Kentucky, according to the Georgetown Center for Children and Families — and experts anticipate bigger jumps, straining state budgets, in the coming months. So far, during the pandemic, nearly 800,000 people have signed up for new private plans through the law’s marketplaces.
In Boise, Idaho, Jeremy Bratsman was laid off from his job as a regional manager in January, and was still searching for work when the economy started shutting down in March. Mr. Bratsman, 43, has Type 1 diabetes; a few years ago, he paid $15,000 for insulin and other supplies over the course of a year while uninsured. Now, though, he qualifies for Medicaid with his wife and four sons because Idaho expanded the program in January.
“I’ve talked to other uninsured diabetics,” his wife, Rebecca Bratsman, said. “And when they are in one of those states that hasn’t expanded, I just tell them to move. They don’t have any option.”
In states that do not run their own A.C.A. marketplaces, Republican efforts to weaken the law have made enrollment in new private plans during the pandemic more challenging. For example, the Trump administration all but eliminated funding for outreach in those states, including grants to nonprofit organizations that help people enroll in new coverage. Anyone who becomes uninsured after losing a job is eligible to sign up for a marketplace plan for 60 days afterward, but the administration has done little to raise awareness.
Frequently Asked Questions and AdviceUpdated June 24, 2020
What’s the best material for a mask?Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles.
Is it harder to exercise while wearing a mask?A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
I’ve heard about a treatment called dexamethasone. Does it work?The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
What is pandemic paid leave?The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
Does asymptomatic transmission of Covid-19 happen?So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
What’s the risk of catching coronavirus from a surface?Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
How does blood type influence coronavirus?A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
How many people have lost their jobs due to coronavirus in the U.S.?The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
What are the symptoms of coronavirus?Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
How can I protect myself while flying?If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory Universityfound that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
What should I do if I feel sick?If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
Morgan Childers, of Cullowhee, N.C., tried navigating the federal marketplace’s website, HealthCare.gov, after she lost her job at a university in late March. Her income was low enough to qualify for premium subsidies, but she did not figure that out and mistakenly thought her cheapest option would cost $610 a month.
So Ms. Childers, 30, signed up for Cobra, which lets laid-off workers stay on their former employer’s health plan for 18 months under federal law, but requires them to pay the full cost unless the employer chooses to help. She is paying $560 a month — substantially more than a subsidized plan would cost at her income level, and an amount she will not be able to afford for long. She has several autoimmune conditions, and without insurance, would owe at least $3,000 a month just for her oral medications; she also gets regular infusions that cost even more.
“If my unemployment runs out and I don’t have a job,” she said, “I don’t know what I’ll do.”
In contrast, most of the 13 states that operate their own A.C.A. marketplaces not only opened enrollment to everyone during the pandemic, but worked hard to publicize the option. In California, where the special enrollment period started on March 15 and was recently extended through the end of July, the marketplace devoted $9 million to advertising the opportunity, including two television spots. People on unemployment get a flyer advertising the marketplace with every check, and dozens of community groups help people enroll. So far, more than 175,000 have done so.
In the District of Columbia, where the special enrollment period will extend through September, the marketplace is contacting businesses that are cutting jobs to offer affected employees help applying for Medicaid or premium subsidies. In Maryland, where the marketplace just extended its special enrollment period through July 15, people can check a box on their tax form to find out if they are eligible for free or subsidized coverage.
A new report from the Trump administration said that, by the end of May, about 487,000 people who had lost their job-based coverage had signed up through the federal marketplace.
Unlike during the last recession, many employers are trying to maintain coverage for workers whom they have furloughed or laid off, hoping they can bring them back when the economy improves. About half of employers, asked in an April survey whether they planned to continue paying for health benefits for furloughed employees, said they would for a month or longer, according to an informal survey from Mercer, a benefits consultant.
There are no estimates of how many newly jobless people have enrolled in Cobra. Many employers are pushing Congress to pay people’s premiums under Cobra during the pandemic so workers can keep the coverage they had through work.
Proponents — including Republican opponents of the Affordable Care Act — say the idea is gaining momentum and could be included in the next coronavirus legislation. The latest estimate for the cost of covering the premiums in full is $98 billion.
But House Democrats are also pushing an alternative: a bill that would increase federal premium subsidies to buy plans through the A.C.A. marketplaces and make them available to people who earn more than 400 percent of the poverty level, the current cutoff for assistance. The legislation mirrors what Mr. Biden has proposed. It has no chance of passing the Republican-controlled Senate, but Democrats hope it will bolster their election-year case against Mr. Trump and other Republicans.
Even before the pandemic, one out of every 10 people in the United States had no health insurance, despite the uninsured rate reaching a record low in 2016. They included undocumented immigrants and those in the Medicaid coverage gap, but also people whose income was too high to qualify for marketplace subsidies or who could not afford even a subsidized plan.
Brian Golembiewski, 47, who works for a land brokerage company in Ludington, Mich., said he could not afford the insurance through his job or a subsidized A.C.A. plan for his wife and himself.
“I like that they made an effort with Obamacare,” he said, “but it fell way short.”
Obamacare Faces Unprecedented Test as Economy Sinks - The New York Times