Intro: ACA at 11

This month, President Biden signed the American Rescue Plan into law, including the boldest expansion of health care in a decade. This historic moment comes after years of relentless Republican attacks on the Affordable Care Act. Critics of the ACA and political prognosticators alike would not have been able to imagine this unprecedented achievement at the start of the Trump administration. Our celebration of this monumental legislation coincides with the 11th anniversary of the passage of the ACA. Over the last year, the ACA has served as a lifeline to Americans battling the COVID-19 pandemic, and there’s never been a more urgent time to build on the law’s success. 

Along with desperately needed pandemic relief, the American Rescue Plan builds on the foundation of the ACA by lowering costs, expanding coverage, and reducing racial disparities in care. After more than a decade of Republican attacks on the ACA, Americans are finally getting the improvements to health care policy they need. The American Rescue Plan provides critical resources that will pull our country out of the pandemic and have a lasting impact on health care for years to come.

The American Rescue Plan and the COVID-19 Pandemic:

The American Rescue Plan is a historic accomplishment that will help end the pandemic by putting cash in the hands of American families, surging vaccine distribution, and reopening schools and the economy. It also will lower health insurance premiums for millions of American families, create additional tax credits for coverage, incentivize Medicaid holdout states to expand their programs under the ACA, and allow states to expand Medicaid coverage for new mothers one year postpartum. The American Rescue Plan will also increase funding to provide health services for communities of color by expanding Community Health Centers and investing in health services on tribal lands. These steps are critical to get the pandemic under control, expand coverage, address inequities, and reduce health care costs. 

Where We Go From Here:

The American Rescue Plan is a huge step forward in expanding coverage and lowering health care costs, but there is still more work to be done to make sure President Biden and Democrats are able to deliver on their health care promises. Voters put Democrats in control because they were tired of Republicans’ endless attacks on health care, including their repeated attempts to repeal the ACA both legislatively and through the courts, and their inability to provide meaningful pandemic relief. Many of the historic health care provisions in the American Rescue Plan that will change Americans’ lives and their ability to access health care are temporary. We must work to make these changes in coverage and cost permanent. 

We must also be sure that states that have refused to expand Medicaid take full advantage of the American Rescue Plan’s new incentives, or if they refuse, develop additional measures to get these millions of people covered. Additionally, we must give Medicare the ability to negotiate for lower drug prices. This change would directly address one of the biggest concerns Americans face — skyrocketing prescription drug prices. The single most effective way to lower drug costs is allowing Medicare to negotiate prices. In 2019, House Democrats passed the Lower Drug Costs Now Act (H.R. 3), a plan to lift this ban and reduce drug prices for all Americans with insurance, not just those on Medicare. 

The Democratic health care agenda – building on the Affordable Care Act by expanding access, lowering costs, strengthening protections and addressing inequities – is overwhelmingly popular with Americans, no matter their political party. No other issue has the power to bring voters together in this way.

Finally, we’re still awaiting a decision in California v. Texas, the Republican lawsuit that could completely dismantle the Affordable Care Act. The Supreme Court heard oral arguments in November and could issue a ruling at any time between now and June. If the court rules in favor of the ACA, it is clear proof that the law is here to stay. If the court strikes down all or part of the law, our entire health care system will be thrown into chaos in the middle of a pandemic. Republicans would own that disaster, and Congress will need to be prepared to take quick, decisive actions to reinstate the overwhelmingly popular health care law. 

This packet provides fact sheets and message guidance on all these issues. If you’d like to work with Protect Our Care in your district, contact Anne Shoup at [email protected].

American Rescue Plan Talking Points: Lowering Health Care Costs, Increasing Coverage, & Reducing Racial Inequities

• In rural, suburban and urban areas, American families have struggled this year with the COVID-19 pandemic – a massive public health crisis that was made worse by the failures of the Republican administration. People have lost livelihoods and lives, been separated from loved ones and left afraid of this virus.
• To get control of the virus, more Americans need health care coverage and lower costs so that’s what the American Rescue Plan does. The American Rescue Plan is the boldest expansion of health care in a decade in order to lower health care costs, expand coverage, and address inequities in care. 
  • Associated Press: COVID bill to deliver big health insurance savings for many
  • CNBC: The $1.9 trillion stimulus bill would make health insurance more affordable for millions
  • Kaiser Health News: Pandemic Aid Package Includes Relief From High Premiums

• The Affordable Care Act has been a lifeline for Americans as they battle the coronavirus pandemic, and there has never been a more urgent time to build on it. The ACA is at a high in favorability of +15-points (54%-39%).
• Millions have lost their job and health insurance because of this pandemic and millions more need health care so they don’t get sick. The American Rescue Plan means:
• Lower health insurance premiums for millions of American families. A family of four making $90,000 could see their monthly premium come down by $200/month.
• Makes health care more affordable for low-and middle-income Americans with new tax credits so millions of families won’t have to pay anything more than 8.5% of their income for coverage. 
• Eliminate the cost of health insurance for people collecting unemployment insurance after losing their jobs because of the pandemic
• Incentivizing Medicaid expansion in the 12 remaining holdout states, making coverage available to as many as 4 million more uninsured adults
• There are too many Black, brown and tribal communities in America who don’t have the same access to health care — and the COVID pandemic exposed the problem clear as day. The American Rescue Plan works to reduce racial inequities in our health care system: 
• Letting states expand Medicaid coverage for new mothers one year after giving birth so we can reduce the skyrocketing rates of maternal mortality in underserved communities. 
• Increases funding to provide health services for communities of color by expanding Community Health Centers and investing in health services on tribal lands.
• Makes new investments in expanding Medicaid, and according to the Center on Budget and Policy Priorities, people of color make up nearly 60 percent of the people who could gain coverage in the remaining non-expansion states. 
• The American Rescue Plan has bipartisan support among 7-in-10 Americans and bipartisan support among elected leaders in red states and blue states.
• Congress had a choice to make: whether to act swiftly to rescue Americans from the virus with the health care they need or continue to prolong it. Congress backed President Biden’s plan, but too many Members of Congress stood in opposition. 

ACA at 11: Building On The Success Of The Health Care Law

Eleven years ago, the Affordable Care Act (ACA) became the law of the land and millions of Americans gained coverage and critical protections as a result. After four long years of Republican efforts to repeal and sabotage the law, President Biden and Democrats in Congress are now building on the strong foundation of the ACA to expand coverage, lower costs, and reduce racial disparities in health care. These steps are essential as millions have lost their jobs and their health insurance during the COVID-19 pandemic. 

A closer look at how the Affordable Care Act is working across the country:

• More than 20 million Americans gained health coverage. Because of the ACA, more than 20 million Americans gained health coverage.
• More than 11 million people have coverage through the individual market — and this number is growing. In 2020, 11.4 million people were covered by marketplace plans. This number is expected to grow after President Biden opened a special enrollment period (SEP) in response to the COVID-19 pandemic; in just the first two weeks of the SEP, more than 206,000 Americans signed up for coverage. 
• Protections for 135 million Americans with pre-existing conditions. Because of the ACA, insurers in the individual market can no longer drop or deny coverage, or charge you more because of a pre-existing condition. More than 135 million Americans have a pre-existing health condition. And without the ACA, millions of Americans who have contracted the COVID-19 would likely be deemed as having a pre-existing condition and be at the mercy of their insurance companies who could refuse to pay for needed care. 
• Women no longer charged more than men. Because of the ACA, insurers can no longer charge women more than men for the same coverage, and insurers are now required to cover important health benefits like maternity care. Before the ACA, 75 percent of non-group plans refused to cover maternity care.
• Ended annual and lifetime limits. Because of the ACA, insurers can no longer put annual or lifetime limits on the care you receive.
• Young adults can stay on their parents’ plan until age 26. Because of the ACA, roughly 2.3 million young adults have coverage because they can stay on their parents coverage until age 26.
• Allowed states to expand Medicaid. Because of the ACA, states can get additional federal money to expand Medicaid. Roughly 15 million Americans had coverage through Medicaid expansion before the pandemic. Between February and November 2020, states that expanded their programs saw a 22 percent increase in Medicaid enrollment. Additional research has shown that Medicaid expansion states are better positioned to handle the economic fallout of the pandemic, with fewer residents becoming uninsured. 
• Free preventive care. Because of the ACA, health plans must cover preventive services — like flu shots, cancer screenings, contraception, and mammograms – at no cost to consumers. This includes nearly 137 million Americans, most of whom have employer coverage. Importantly, the ACA requires plans to cover all vaccinations recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP), including vaccines for coronavirus.  
• Comprehensive Coverage. Because of the ACA, insurers have to cover what are known as “essential health benefits,” such as maternity care, prescription drugs, and substance and mental health. As it stands, ACA-compliant plans must cover COVID-19 testing, treatment, and hospitalization. 
• Tax credits are available to help people afford coverage. Because of the ACA, most people getting coverage on the marketplace qualify for tax credits to help pay for coverage. 9.6 million of the ACA’s 11.4 million marketplace enrollees receive premium tax credits. 
• Improved access to care and financial security. Between 2010 and 2018, the share of non-elderly adults with a problem paying a medical bill fell by 17 percent, the share who didn’t fill a prescription fell by 27 percent, the share who skipped a test or treatment fell by 24 percent, and the share who didn’t visit a provider when needing care fell by 19 percent.
• Helping seniors afford prescription drugs. Because of the ACA, the Medicare prescription drug donut hole is closed. From 2010 to 2016, “More than 11.8 million Medicare beneficiaries have received discounts over $26.8 billion on prescription drugs – an average of $2,272 per beneficiary,” according to a January 2017 Centers on Medicare and Medicaid Services report.
• Helping increase access to employer-sponsored coverage. The Affordable Care Act’s individual and employer mandates are credited with helping increase rates of employer-sponsored health insurance. The Kaiser Family Foundation estimates that between 2013 and 2017, seven million more people gained employer coverage.
• Key Support For Rural Hospitals. The ACA led to a $12 billion reduction in uncompensated care costs. Between 2013 and 2015, hospitals’ uncompensated care costs decreased by $12 billion, or roughly 30 percent. Rural hospitals have already taken a serious financial hit during the pandemic, and as hospitals across the country continue to face an influx in patients, the ACA helps ensure providers are paid for the treatment they provide. 
• Reducing Racial Disparities. The pandemic has taken a disproportionate toll on communities of color nationwide. The ACA helped reduce longstanding racial disparities in coverage rates, improving health care access for communities of color across the board. The ACA helped lower the uninsured rate for nonelderly African Americans by more than one third between 2013 and 2016, and the percentage of people gaining health insurance under the ACA was higher for Latinos than for any other racial or ethnic group in the country. The ACA also cut uninsurance rates among Asian Americans by more than half. 
• Coverage For Frontline Workers. Frontline workers, including health care workers, rely on the ACA for comprehensive, affordable care. Without the ACA’s protections for pre-existing conditions, health care workers could be discriminated against by their insurance companies for having contracted or even being exposed to coronavirus. Additionally, many workers deemed “essential” during the pandemic, such as grocery store employees, do not receive employer-based coverage and therefore stand to benefit from the ACA’s individual marketplace coverage options and Medicaid expansion. Research has shown that the ACA helped half a million direct care workers gain coverage.

The American Rescue Plan Will Expand Coverage, Dramatically Reduce Health Care Costs For Americans

On March 11, President Biden signed the American Rescue Plan into law, historic legislation that includes measures to expand coverage and to dramatically lower health care costs for millions of Americans. The American Rescue Plan builds on the strong foundation of the Affordable Care Act (ACA) to lower premiums for people purchasing coverage through the marketplaces and expand access to financial assistance for more middle-class families. Additionally, the American Rescue Plan includes robust financial incentives for the 14 states that have not yet implemented Medicaid expansion.  

Making health insurance more affordable and accessible is especially important as the country continues to battle the coronavirus pandemic and millions have lost their jobs and their health insurance. Measures to increase affordability also reduce racial disparities in health care access. Despite significant progress after the implementation of the ACA, Black and Hispanic adults are more likely than white adults to have low incomes and face financial barriers to receiving care. 

Lower Costs

Increasing financial assistance on the ACA marketplaces means more people will be able to get the affordable coverage they need during the pandemic. In addition to lowering costs for the nine million people currently receiving financial assistance on the marketplace, the American Rescue plan makes generous subsidies available to 14.9 million uninsured people, according to estimates from the Biden administration. Per the New York Times: “For someone earning over $51,000, new subsidies could lower premiums by as much as $1,000 a month in the country’s most expensive markets.”

• Guarantee coverage that costs less than 8.5 percent of income. This legislation lowers the cost of premiums for Americans purchasing coverage through the ACA marketplaces, ensuring enrollees have the option to purchase health care for less than 8.5 percent of their income for the next two years. Under current law, families earning just above 400 percent of the federal poverty level spend an average of 15 percent of their incomes on health insurance. 
• Make coverage more affordable by temporarily expanding the eligibility for premium tax credits above 400 percent of the federal poverty level — roughly $51,000 for a single person or $105,000 for a family of four. An estimated 3.4 million people earn too much to qualify for subsidies and remain uninsured. According to estimates from the Center on Budget and Policy Priorities, under the American Rescue Plan: 
• The average 45-year-old earning $60,000 will save $86 in monthly premiums. 
• A 60-year-old couple with a household income of $75,000 will save $1,389 in monthly premiums. 
• A family of four with a household income of $120,000 will save $595 in monthly premiums. 
• Improve affordability for low- and middle-income Americans by increasing the size of the tax credits for all income brackets for the next two years. This means a typical family of four with a household income of $75,000 will save $248 on monthly premiums, while a single adult earning $30,000 will save $110 per month. The Biden administration estimates that four out of five enrollees will be able find a plan for $10 or less per month after tax credits.
• Eliminate premiums in the exchanges for people earning up to 150 percent of the federal poverty level (roughly $19,000 for a single person and $39,000 for a family of four) and for those receiving unemployment insurance in 2021. Families USA estimates that more than four million uninsured workers relying on unemployment insurance stand to benefit from this extension of premium subsidies. 

Expanded Coverage

In addition to providing affordable coverage options for millions of uninsured Americans through the ACA, the American Rescue Plan provides robust financial incentives for the 14 states that have not implemented Medicaid expansion. Two of these states, Oklahoma and Missouri, have adopted expansion but not yet implemented the program. The remaining 12 states have rejected expansion entirely. Research confirms that Medicaid expansion increases access to care, improves financial security, and leads to better health outcomes. Medicaid expansion has played a vital role in reducing racial disparities in health care access and has served as a critical safety net during the pandemic. 

An estimated four million uninsured adults — including 640,000 frontline workers, 500,000 people with disabilities, and 926,000 older adults aged 50 to 64 — could gain coverage if the remaining holdout states adopted expansion. Importantly, people of color make up nearly 60 percent of this group. 

• More than 6 million Americans could gain Medicaid coverage if every remaining state expands Medicaid under the American Rescue Plan. Pre-pandemic estimates from the Urban Institute found that roughly 6 million people would enroll in Medicaid if the remaining states implemented expansion. 
• Even after paying the cost of Medicaid expansion, these states would receive an additional $9.6 billion in new federal funding that they could use to offset spending in other state programs or budget shortfalls. According to estimates from the Kaiser Family Foundation, the 14 states that have not yet implemented Medicaid expansion would receive $16.4 billion thanks to the enhanced federal match rate under the American Rescue plan, while the total cost of Medicaid expansion in these states would only be $6.8 billion.

Addressing Racial Disparities In Health Care

The health care measures in the American Rescue Plan will have profound impacts in racial disparities in health care access and outcomes. COVID-19 has hit communities of color much harder than others. In addition to expanding health care access, the American Rescue Plan includes funding to provide health services for underserved populations, including expanding Community Health Centers and investing in health services on tribal lands. The American Rescue Plan: 

• Makes Health Coverage More Affordable. Expanding the number of middle class families who can get financial support and increasing the amount of financial assistance available will mean millions of Americans will see their premiums reduced. This is especially important for Black and Latino families, who, even before the coronavirus crisis, saw higher unemployment rates and lower median wealth than white people, and now are suffering even more from the economic fallout of the pandemic. 
• Coverage Gains Under The ACA Suggest Expansion Of The Health Care Law Will Benefit Communities Of Color. The ACA helped reduce longstanding racial disparities in coverage rates, improving health care access for communities of color across the board. The ACA helped lower the uninsured rate for nonelderly African Americans by more than one third between 2013 and 2016, and the percentage of people gaining health insurance under the ACA was higher for Latinos than for any other racial or ethnic group in the country. The ACA also cut uninsurance rates among Asian Americans by more than half. 
• People Of Color Remain More Likely To Struggle To Afford Care. Despite significant progress after the implementation of the ACA, Black and Hispanic adults are more likely than white adults to have low incomes and face financial barriers to receiving care. Research from the Centers for Disease Control and Prevention found that while there has been a drop in the number of people struggling with medical bills since 2011, this decline  slowed under the Trump administration, and Black and Hispanic respondents remain significantly more likely than white respondents to report concerns about paying these bills.
• Incentivizes Medicaid Expansion. Medicaid expansion has played a vital role in reducing racial disparities in coverage, but stark disparities remain in the 12 states that have rejected expansion. According to the Center on Budget and Policy Priorities, people of color make up nearly 60 percent of the people who could gain coverage in the remaining non-expansion states. 
• Invests Billions In Vaccine Distribution. The American Rescue Plan allocates billions to continue ramping up a national vaccination campaign, including by setting up community vaccination clinics, deploying mobile units, and fortifying the vaccine supply chain. Efforts to increase vaccination distribution will be especially beneficial in communities of color and hard to reach populations. Based on states reporting vaccination data by race and ethnicity, Black and Hispanic people continue to receive smaller shares of vaccinations compared to their shares of cases and deaths and compared to their proportions of the total population.
• Expands Medicaid Coverage To New Mothers One Year Postpartum. Black women are three to four times more likely to die of complications related to pregnancy and childbirth compared with white women. The bill works to address the maternal mortality crisis by enabling states to expand Medicaid coverage to new mothers 12 months postpartum. 
• Boosts Funding For Community Health Centers. The American Rescue Plan includes $7.6 billion for Community Health Centers, critical sources of care for underserved populations. The package also includes major investments in health services on tribal lands. These funds will support the expansion of COVID treatment and care, as well as provide the vaccine to underserved populations.

Why Should States Expand Medicaid?

Despite the overwhelming benefits of Medicaid expansion, Republicans have spent years undermining the ACA and its expansion of Medicaid at every turn, blocking millions from coverage. Yet the program has become increasingly popular among conservative voters. In 2020, the country saw voters in two deeply conservative states, Oklahoma and Missouri, approve expansion. 75 percent of Americans have a favorable view toward the Medicaid program, and 61 percent of Americans in non-expansion states favor expansion. 

*Voters in Missouri and Oklahoma have approved expansion in 2020, but these states have not yet implemented the program. Both states are eligible for enhanced funding under the American Rescue Plan. 

Medicaid Expansion Saves Lives. 

• Reduced mortality in adults by nearly 4 percent. A study published in the Journal of Health Economics found that Medicaid expansion reduced mortality in people aged 20 to 64 by 3.6 percent.
• Saved the lives of at least 19,200 older adults. According to the Center on Budget and Policy Priorities, Medicaid expansion saved the lives of 19,200 older adults aged 55 to 64 between 2014 and 2017. At the same time,15,600 older adults died prematurely as a result of their states’ decision not to expand the program. 
• Reduced cancer and heart-related deaths. While scientific advancements have led to improved prognosis for many diseases, Medicaid expansion increased access to care and, subsequently, improved disease outcomes. Between 1999 and 2017, cancer deaths dropped more in states that expanded Medicaid coverage under the ACA than in states that rejected expansion. Additionally, research presented at the American Heart Association’s Scientific Sessions found that Medicaid expansion was tied to fewer heart-related deaths. 
• Reduced infant & maternal mortality. Multiple studies draw the connection between Medicaid expansion and reduced infant and maternal mortality rates. One study published in the American Journal of Public Health found the gains made in reducing infant mortality was more than 50 percent greater in states that expanded Medicaid, compared to those that did not. 

Medicaid Expansion Leads To Better Health Outcomes.

• Improved health of enrollees. A survey of more than 3,000 Michigan Medicaid expansion enrollees found that the percentage of those reporting poor health days decreased over time, with the biggest decreases among Black and low-income patients. Similar research showed that patients in expansion states were less likely to report declining physical and mental health. Additionally, one study shows that tobacco users were more likely to quit in Medicaid expansion states.
• Improved infant & maternal health. The uninsured rate for women of childbearing age in non-expansion states is nearly double than in states that expanded their programs (16 vs. 9 percent). Research from the Georgetown Center for Children and Families found that Medicaid expansion has helped fill gaps in maternal health coverage, leading to healthier mothers and babies. It also helps new mothers maintain access to coverage and important postpartum care after giving birth. 

Medicaid Expansion Helps People Access Treatment & Preventive Care. 

• Increased access to preventative care, cancer screenings and disease-specific treatment. Medicaid expansion has helped patients access preventative care, including colon cancer screenings. Expansion also increased patient access to kidney transplants and made diabetes medication more affordable for low-income patients. The program was also tied to earlier diagnosis of colorectal cancer and reducing diabetes-related amputations.
• Improved access to primary care & family planning. Two studies from Michigan showed that Medicaid expansion doubled low-income patients’ access to primary care, and that enrollees experienced improved access to birth control and family planning. 
• Increased access to substance abuse treatment. Study after study has shown that Medicaid expansion has increased access to addiction treatment and mental health services. And new research shows that as many as 8,132 people were saved from fatal opioid overdoses as a direct result of Medicaid expansion.
• Increased coverage for children. When parents have health insurance, their children are more likely to be insured. A study in Health Affairs found that 710,000 children gained public coverage as a result of their parents enrolling in Medicaid between 2013 and 2015. 

Medicaid Expansion Reduces Racial Disparities In Health Care. 

• Reduced racial disparities in health insurance coverage and access to care. The ACA led to historic reductions in racial disparities in access to health care, but racial gaps in insurance coverage narrowed the most in states that adopted Medicaid expansion. Per the Commonwealth Fund: “Coverage disparities in expansion states narrowed the most over the period…The black–white coverage gap in those states dropped from 8.4 percentage points to 3.7 points, while the difference between Hispanic and white uninsured rates fell from 23.2 points to 12.7 points.” 
• Reduced disparities in infant and maternal health. One study found that reductions in maternal mortality in expansion states were concentrated among Black mothers, “suggesting that expansion could be contributing to decreasing racial disparities in maternal mortality.” Expansion has also been tied to improving health outcomes for black babies, significantly reducing racial disparities in low birth weight and premature birth. 
• Better access to care. Medicaid expansion reduced racial disparities in cancer care and resulted in earlier diagnosis and treatment for Black patients. According to the Center for American Progress, Black women were more likely to receive care because of the ACA.

Medicaid Expansion Improves Financial Security. 

• Reduced income inequality. A January 2021 study from Health Affairs found that the ACA helped reduce income inequality across the board, but much more dramatically in Medicaid expansion states. The bottom 10th percentile of earners In Medicaid expansion states saw a 22.4 percent boost in their income, compared to 11.4 percent in non-expansion states. A study in Health Affairs found that Medicaid Expansion also caused a “significant” reduction in poverty. 
• Reduced medical debt. The chance of accruing medical debt is 20 percent lower in states that have expanded Medicaid. Additionally, a 2018 National Bureau of Economic Research analysis found that Medicaid expansion led to a nearly $6 billion decline in unpaid medical bills and to higher credit scores. 
• Lowered uncompensated care costs. Medicaid expansion has saved hospitals an average of $6.4 million In uncompensated care costs. In 2017, uncompensated care costs comprised 6 percent of total expenses for hospitals in states that rejected Medicaid expansion—double the amount for hospitals located in expansion states. Additional research shows that expansion states saw a reduction in preventable hospitalizations and lower hospital costs. 
• Increased hospital profits. More than 120 rural hospitals have closed since 2010. The vast majority closed in states that had not expanded Medicaid at the time of the hospital closure. Research confirms that expansion increased rural and safety-net hospital profit margins. 
• Boosted employment. Reports from Ohio and Michigan found that Medicaid expansion helped enrollees hold down jobs and look for work. Relatedly, a study from the University of Kansas found that people with disabilities are much more likely to be employed in states that have expanded Medicaid coverage. Additionally, the number of people who report not working because of a disability declined in expansion states.  

State-By-State Fact Sheets