Professional Documents
Culture Documents
Finaldraft
Finaldraft
Finaldraft
UWRT 1102-027
25 April 2017
Since the Affordable Care Act's implementation in 2010, it has been at the dead center of
nationwide controversy. Studies show that the Affordable Care Act, commonly referred to as the
ACA, is supported by over half of Americans (Dalen et al. 807). The ACAs primary goals are to
improve the health of Americans by increasing their access to health insurance, improve the
quality of care, and reduce the high costs of coverage (Dalen et al. 807). So far, the ACA has
proved itself to be quite effective, as it has provided a net total of 16.9 million previously
uninsured Americans with coverage as of 2015 (Health Insurance Grows). There is no doubt that
this is a substantial number, which makes the talk of a repeal increasingly concerning. This often
proposes the question: If the ACA were repealed, how would this impact the American public? It
has been found that many of these newly insured Americans are vulnerable, as they are
ethnic minority (Steinbrook, et al.). A repeal of the Affordable Care Act would have a
low-income women, and the homeless, as they would lose their access to readily available
The Affordable Care Act is an act that was passed March of 2010 that successfully
Care Act History). This is mainly due to its provisions for state-based Medicaid expansion and
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subsidies to assist middle and lower income individuals in purchasing private health insurance
(Affordable Care Act History). An idea to overhaul the American health care system to
implement a nationwide healthcare structure is hardly new, it just was not successfully executed
until former President Barack Obamas time in office (Affordable Care Act History). A
considerable number of Americans across the political spectrum were discontented with the state
of the health care system prior to the ACA, and called for a change.
The state of Americas healthcare system prior to the ACA was plagued with problems,
with many private insurance companies having the freedom to deny those with pre-existing
conditions, and drop peoples coverage when they reached their lifetime limits (Basu 5).
Employer-based insurance is and has been the most widely utilized health coverage outlet in
America (Health Insurance). A noteworthy downfall to this popular system is that employer-
based health insurance can sometimes entail a lack of options, as many employers have only a
select amount of health care plans for their employees to choose from (Basu 5). The health care
options provided might not be suitable for every specific individuals health care needs (Basu 5).
Prior to the ACA, if an individual were to lose their job or choose to take time off, they would
then need to find coverage through the individual market (Basu 5). If one were to develop a
medical condition after leaving their previous employer, they would be subject to higher
premiums or denial when applying for insurance due their pre-existing condition (Basu 5). This
system was problematic for many, especially those unemployed or with chronic illnesses (Basu
5). The inequalities that those groups faced when seeking coverage was one of the driving forces
in the institution of new health care reform. After the ACA was passed in Congress, it granted
protections for the public from harmful insurance practices, which was one of its fundamental
One of the ACAs most significant and controversial provisions is a mandate, specifically
referred to as the individual shared responsibility payment, which requires that Americans obtain
health coverage, or else pay a penalty (Eibner and Price). The mandate is perhaps one of the
ACAs components most riddled in controversy, as opponents argue that the mandate infringes
on individual rights, and often deem the mandate unconstitutional (Eibner and Price). Proponents
for the law claim that without the mandate, millions who would have otherwise signed up for
coverage would be uninsured (Eibner and Price). This debate emerges into conversations all over
the nation between politicians, healthcare providers, and the general public, with many taking
vastly different stances. With all arguments aside, the evidence is clear. Without healthy
individuals paying into the health care system, there will not be enough funds to cover those who
need frequent treatment (Eibner and Price). By requiring that Americans acquire health insurance
or pay a fine, it eliminates the facile route to forgo coverage in the hopes that one will remain in
optimal health. Ideally, with healthy and ill Americans paying their premiums, there will be
enough revenue to adequately cover individuals when treatment is necessary (Eibner and Price).
If the mandate were repealed and enrollment rates were to fall, there would not be enough funds
to cover those who need costly coverage. If one were to be involved in an accident or fall ill,
their insurance plan would likely be unable to cover the costs of their medical treatment
adequately, leaving them with out-of-pocket costs. For many, particularly low income
populations, the ability to pay their debt is oftentimes out of the question. Not only do situations
such as this weigh these groups down with financial burdens, but it greatly decreases their
Medicaid expansion has had one of the most profound impacts on the vulnerable
populations access to affordable coverage (Hoadley and Searing). The Affordable Care Act does
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not require, but instead encourages states to expand their Medicaid programs through generous
federal funding incentives to assist in the management of costs for the coverage of new
individuals (Brandon). Beginning in 2014, all individuals in families with a modified adjusted
gross income of 138% federal poverty line or less who are under the age of sixty-five and not
already covered, are permitted to enroll in Medicaid (Brandon). This number is referring to states
that have opted to expand their Medicaid programs and accept the federal funding. Prior to the
provisions in the ACA, many low income groups found themselves ineligible due Medicaids
specific restrictions and variance across state lines (Brandon). States that have expanded their
Medicaid programs have experienced an increase in their ability to provide health care to
vulnerable populations more successfully (Hoadley and Searing). Medicaid recipients in these
states no longer grapple with daunting medical bills, in turn assisting the financial bottom line for
safety-net clinics and hospitals, as patients are more likely to pay for their care due to their
improved financial status (Hoadley and Searing). The money that hospitals would have
traditionally had to use to cover uncompensated care can instead be invested in efforts to provide
improved care and preventative treatment options (Hoadley and Searing). With money being
invested into programs such as these, it facilitates research, further increasing the rate of the
eventually leads to better overall health outcomes for virtually all groups.
Since the ACA was in its infancy, there has been disagreement on all ends of the political
spectrum (Dalen, et al. 808). Health care policy is an highly complex partisan issue, and
oftentimes does not have a solution that will be mutually agreed upon by all parties involved. For
example, when the Affordable Care Act was passed by Democratic majorities in the House and
Senate, 219 out of 253 Democratic party leaders voted yes, with all Republican party leaders
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voting no (Dalen, et al. 808). Much of the conversation has continued to revolve around the
ethical and financial impacts of the ACA. Due to the wide scope of this issue, and the sheer
thousands of authors writing about it, it is not often that they directly reference each other, but
many times their arguments coincide and utilize the same or similar resources and are in favor of
some component of the ACA. For example, Jared Fox and Wanda Barfields article Decreasing
Unintended Pregnancy Opportunities Created by the Affordable Care Act delves into how the
ACAs policies have improved womens access to reproductive care (1), while Lauren R.
Frylings article Homeless Persons Barriers to Acquiring Health Insurance through the
Affordable Care Act discusses how the Affordable Care Act has improved homeless
populations access to healthcare and information regarding Medicaid enrollment. They both
detail how the Affordable Care Act has impacted individuals positively, but center their focus on
a specific group of individuals, which seems to be a trend for a multitude of scholarly articles
concerning the ACA. It was also found that authors who wrote articles about the ACA were
likely to write multiple pieces regarding the ACA in some form. Christine Eibner, author of
How Would Eliminating the Individual Mandate Affect Health Coverage and Premium Costs
and Assessing Alternative Modifications to the Affordable Care Act: Impact on Individual
Market Premiums and Insurance Coverage, uses her expertise to discuss in both articles how
low income individuals access to health coverage through the individual market would be
hindered if an ACA repeal were to take place. In each article, her primary focus is different, but
her arguments coincide as they not only relate to each other, but can be used interchangeably to
reinforce each argument. Aside from her credentials, this strengthens her reliability as an author.
multiple perspectives surrounding an issue. While not all of these articles shed light on the same
issues or agreed on each component, their variability allowed for a stronger argument.
While the conversation is expansive, most authors are failing to connect how policy
changes would affect low income individuals in a practical sense, and often focus on one specific
group instead of discussing the effects of a repeal on low income individuals as a whole. They
also flood their articles with field-specific terminology that is likely challenging for a reader with
little to no background knowledge. This essay provides in-depth information as to how specific
policy changes would affect low income populations, but discusses these populations in a
relatively general sense so readers can gather a comprehensive understanding of the impact a
repeal would have nationwide. This essay also breaks down the difficult terminology, while
remaining informative, which is not being done by other scholarly authors. While there are many
facets of the ACA that must be considered, it is undeniable that the implementation of the ACA
has had an overwhelmingly positive impact on low income populations in America, with more
than 10 million newly covered individuals in just 2014 (Dalen, et al. 808).
By merely observing the facts, it is apparent that the Affordable Care Act has had a
ratings, heavy opposition is being heard from Americans nationwide (Dalen et al. 808). With this
information in mind, it poses a pertinent question: If the ACA has had such success in providing
affordable coverage to uninsured Americans as the evidence suggests, where is all this opposition
stemming from? It is likely that biased media influence plays a key role in the nations approval
of the Affordable Care Act. In a study referenced in the article titled, Why Do So Many
Americans Oppose the Affordable Care Act, it was found that after the ACA was fully
implemented in 2014, its overall approval ratings decreased by six percent from 2013, with fifty-
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five percent of Americans being opposed to the individual mandate (Dalen et al. 808-809). This
study reports that sixty percent of Americans reported that the information they had about the
ACA was delivered to them via the television, with ninety-four percent of the $445 million spent
on television advertising for the ACA in 2014 being used to display negative images and
information (Dalen et al. 808-809). This is alarming, as it is widely recognized that numerous
media outlets have their own personal, political, and financial agendas to push. With the spread
health care policy can be easily persuaded into choosing a side. The stance they take, when based
on biases or falsehoods, can be damaging to large groups of people, especially low income
populations, as it directly decreases vulnerable Americans access to affordable health care due to
the likelihood of elected officials coming into power that will work to dismantle or repeal
beneficial programs such as the ACA. Without Americans being exposed to the legitimate effects
of the ACA through reliable facts and statistics, it is unlikely that America will achieve universal
Throughout the course of the 2015-2016 presidential campaign, a dismantle or repeal was
an action promised by nearly every Republican in the race (Carroll). Opponents were ecstatic,
often believing that it would lower their premiums (Dalen et al. 808), promote employment
(Dalen et al. 808), and reinstitute autonomy for Americans when making the decision to purchase
healthcare. Speaker of the House, Paul Ryan, has recently proposed a popular plan that has met
the demands of many Republicans nationwide titled the A Better Way plan, which is backed by
Republican politicians across America, who also, in some cases, are proposing similar health
care plans of their own (Carroll). A Better Way would allow insurance companies to charge
new beneficiaries a price set by the company if the individual did not have continued coverage
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(Carroll). This is problematic, because if people were to lose their continued coverage, due to
loss of employment, for example, they would have to turn to high risk pools (Carroll), locking
them out of the individual market due to a pre-existing condition. It also proposes to change
Medicaid to a block grant program, which is a federal grant system for states to use for social
welfare programs (Carroll). This money would be granted to states, leaving them with the
authority to make the tough calls as to who will be covered, how much coverage will be granted,
as well as how to utilize funds more efficiently (Carroll). Because a block grant is a set amount
of money, if states were to expend over the allotted amount, they would have to cover costs with
outside resources, likely having to tap into their own revenue. This would likely result in the cut
of services for vulnerable populations, as the money for the block grant would not entirely cover
their expenses. Additionally, if the block grant were less than the amount that the state is already
spending on Medicaid, residents would lose access to certain services or even lose their
eligibility entirely due to the internal system changes that would likely have to occur due to the
lack of funds. Low income individuals would suffer the most from a redesign such as this, as
they are oftentimes heavily dependent on the health care services offered by Medicaid. Inability
to access care could only lead to higher mortality rates, uncompensated care costs, and a general
Low income individuals make up a hefty portion of America, with approximately 15.2%
of Americans being below the poverty line in 2015 (Bureau). As of 2016, low income individuals
are usually recognized as having a pre-taxed income below $11,770 (Federal Poverty). For each
individual in one family, $4,160 is allotted to the previous amount (Federal Poverty). For
example, a single individual with one child that makes less than $15,930 is one-hundred percent
of the federal poverty level, or below the poverty line (Federal Poverty). The Medicaid eligibility
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standard is 138% of the federal poverty level, so a single parent of one child can earn up to
$16,394 and still remain eligible for Medicaid in terms of annual income (Federal Poverty). This
is important to note, as the rank of an individuals income, according to the standards set by the
government, will determine how much federal assistance they will be given. For the purposes of
this discussion, low-income individuals will be further subdivided into the unemployed, low
With the national unemployment rate being nearly ten percent when the Affordable Care
Act was passed in 2010 (State Unemployment), a key objective of the ACA was to assist
Affordable Care Act has assisted a net total of 16.9 million Americans in obtaining affordable
coverage, with many of those individuals being unemployed (Health Insurance Grows). As
previously stated, employer-based insurance remains the most widely utilized health coverage
outlet in America (Health Insurance). When an individual loses their job, they customarily lose
their health insurance as well, leaving them unprotected in the event of a medical emergency
(Health Insurance). Prior to the ACA, they would be forced to fork up the money to pay for
private insurance off the individual market, usually having to pay exorbitant premiums,
particularly if said person has developed a pre-existing condition (Health Insurance). However,
since the implementation of the ACA, when an individual purchases insurance from the
companies cannot deny an individual or install waiting periods (Eibner and Saltzman). In
addition to those protections, premium tax credits are now oftentimes offered for those wishing
to purchase private insurance (Eibner and Saltzman). Premium tax credits are refundable tax
credits that alleviate the high costs of insurance off the Health Insurance Marketplace for eligible
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individuals and families with low to moderate income levels (Questions and Answers). These tax
credits have proved to be incredibly beneficial for those who do not qualify to Medicaid, yet
cannot afford the unsubsidized premium rates and out of pocket costs that come with private
insurance (Questions and Answers). Along with the individual mandate, these tax credits
encourage unemployed or lower income individuals who would otherwise forgo purchasing
insurance to get covered (Eibner and Saltzman). With more people being a part of the system, the
market is stabilized, protecting subsidized enrollees from premium increases (Eibner and
credits and abolish the mandate repeal, in turn causing considerable decreases in enrollment rates
and a steady incline of premium costs (Eibner and Saltzman). The analysis estimated that
unsubsidized premiums would rise by 43.3 percent, with enrollment falling by 68 percent,
leading to 11.3 million Americans becoming uninsured (Eibner and Saltzman). In a circumstance
such as this, low income and unemployed individuals will be priced out of the market, leaving
them unprotected without insurance. Their inaccessibility to necessary health care would only
lead to higher uncompensated costs for hospitals, and overall poorer health outcomes for those
individuals.
Low income women are a large group faced with a multitude of issues regarding the
deliverance of affordable care, particularly reproductive care. Since the Affordable Care Act has
been implemented, increased access to affordable reproductive care was made accessible for low
income women (Fox and Barfield). Unintended pregnancy rates are highly associated with low
income levels (Henshaw 27), and are oftentimes accompanied by delayed prenatal treatment and
fetal exposures to tobacco and alcohol (Fox and Barfield). Those factors combine to result in
adverse health outcomes for both the mother and child, as well as poorer social and economic
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outcomes overall (Fox and Barfield). There are approximately 2.8 million unintended
pregnancies every year in the U.S., and while on the decline, more than 430,000 of these
pregnancies occur among adolescents from ages 15 to 19 (Fox and Barfield). The ACA has
worked to decrease unintended pregnancy rates by removing cost barriers for LARC, long-acting
reversible contraception, along with providing services to women such as education and
counseling at no cost (Fox and Barfield). The requirement of insurance companies to provide a
variety of preventative services without cost sharing by the ACA has proven to be effective, but
continues to face challenges due to problematic policies involving reimbursement for health care
providers and an overall lack of awareness (Fox and Barfield). If the Affordable Care Act were to
be repealed, it would likely reverse the improvements that have been made by decreasing
accessibility for those dependent on these LARC methods, in turn likely raising the unintended
pregnancy rates in America. Unintended pregnancies often involve underprepared mothers, who
are usually not in a comfortable position to adequately support a child/ren financially. Due to
this, these children will likely have poorer health outcomes than children living in households
with higher annual earnings, as access to health care could potentially be an obstacle.
Additionally, an underprepared household may not have the dynamic to model healthy behaviors
for young children. Women having access to LARC methods have proven to be the most
effective and allows for women to have more control over their reproductive decisions. This
access results in the best health outcomes for both the mother and baby.
The homeless population in America is not only low income, but perhaps one of the most
vulnerable populations in America, with 1.2 million Americans facing homelessness every year
(Fryling, et al.). Homelessness is generally defined as the absence of stable housing for more
than two months (Fryling, et al.). Examples include, but are not limited to, sleeping in a car,
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outside, or in a shelter (Fryling, et al.). Medicaid expansion under the ACA was designed with
vulnerable populations at the forefront, striving to improve their accessibility to affordable health
care. Most homeless Americans are eligible for Medicaid, however, this is not always made clear
to them (Fryling, et al.). A study was conducted in 2014 that featured a thirty-question survey
including questions about their access to communication, awareness of the ACA, insurance
status, and obstacles when attempting to obtain coverage (Fryling, et al.). This survey was given
to 650 participants over a ten week period (Fryling, et al.). All adult patients in treatment areas of
the emergency department at San Francisco General Hospital on weekdays between 9:00 a.m.
and 5:00 p.m. were considered for enrollment, with 121 of the 650 participants being homeless
(Fryling, et al.). Compared to the survey results of the non-homeless population, homeless
individuals report having less knowledge about the ACA, a weaker understanding of the ACA
and its enrollment process and qualification requirements, as well an increased lack of internet
access (Fryling, et al.). 70% of the homeless subjects were unaware that they qualified for
Medicaid, with 91% of these unsure subjects reporting income levels below 138% of the federal
poverty line, likely making them eligible (Fryling, et al.). However, awareness measures have
been taken to enroll homeless individuals, with service providers playing a significant role by
assisting these individuals with insurance applications and strengthening connections to regular
sources of health care (Winetrobe 147). The ACA has instilled changes in the healthcare system
that enable these populations to access vital health care (Fryling, et al.). In addition to
significantly poorer health outcomes and a lack of improvement in life expectancy rates, a repeal
also would result in higher uncompensated ED costs due to the inability of homeless populations
to see primary care physicians (Fryling, et al.). The ACA has improved their ability to access
services to improve their general welfare, visit primary care physicians for preventative care,
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alleviate pain, and increase their lifespan. Without Medicaid expansion, many homeless
individuals would not have qualified for Medicaid, making their ability to seek health care
With an estimated 15.2% of the population living below the federal poverty line in
America (Bureau), it is critical that these individuals be regarded when radical changes to the
health care system are proposed. There is no evidence to support the claim that a repeal of the
Affordable Care Act would benefit low income populations in any respect. There is evidence to
prove that a repeal or dismantle would have an overall adverse effect on these populations, due to
a decrease in their access to services. Even if not at first, a repeal would eventually result in
higher long-term costs for virtually all parties involved, as well as resulting in poorer health
outcomes and life expectancy rates of vulnerable populations. Americans need to analyze new
health care policies that are proposed carefully, utilizing credible sources to help weigh the pros
and cons, and be aware as to how these proposals will affect them personally, as well as their
peers and members of their community. As a nation, Americans must work together to improve
the welfare of all citizens by urging health care policies that accommodate for all.
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