Valerie Bogart, Director, EFLRPThere is much we do not know – and won’t know for months – about what comes next now that Congress has taken initial steps toward the apparent repeal of the Affordable Care Act (ACA). What we do know is that the ACA has improved the lives of millions of Americans, and its repeal – along with proposals to block grant Medicaid — will affect vulnerable Americans from all age groups and populations.

It is estimated that 18 million people could lose insurance in the first year after repeal of the law, and the number will increase to 27 million the following year. Those affected would include low- and middle-income people enrolled in private plans through the ACA’s online insurance marketplaces as well as those who have taken advantage of expanded access to Medicaid. The repeal would also mean higher costs and fewer protections for people who receive insurance through their employer, or are covered under Medicare.

Since the ACA took effect 16 million Americans have gained coverage through expanded access to Medicaid. A recent report by the Department of Health and Human Services looks at the impact of Medicaid expansion under the ACA in the 31 states that have adopted it. Their findings show that the expansion states have seen a reduction of 9.2 per cent in the number of uninsured adults. There has been increased access to primary care and a greater increase in the use of preventive services. What is more, expanded Medicaid coverage has improved the financial stability for enrollees, who have a reduced likelihood of bankruptcy and a 10.5 per cent decrease in the number of people having trouble paying medical bills. No, the ACA is not perfect. Like all huge programs improvements are needed. But wholesale elimination without a comparable replacement will be catastrophic.

One particularly vulnerable population that gained coverage either through the marketplaces or Medicaid expansion are adults age 55 to 64 – an estimated 4.5 million people who would lose coverage nationwide. Before the ACA, these older individuals were caught in a double bind: they were too young to receive Medicare but were barred from Medicaid in most states, no matter how poor, if they were not disabled and if they no longer had young dependent children at home. (New York was one of the few states that provided coverage for this population before the ACA.) With the potential repeal of the law, these “singles and childless couples” under age 65 will lose coverage and have no way to pay for health care while they wait for years, literally, to be determined disabled or until they reach age 65 and become eligible for Medicare. They are also the first who will face pre-existing condition exclusions if those ACA protections are repealed from private health insurance coverage.

The ACA has increased funding for home-care services, allowing more older people and those with disabilities to stay in their homes and age in their communities. If the law is repealed, more people will be forced into nursing homes, while the loss of financial protections for married couples would mean spending more out of pocket to keep their loved one at home.

The ACA has provided a stable safety net for millions of Medicaid recipients by strengthening the partnership in which the federal government shares with participating states the actual costs of the program. If that fiscal partnership falls away and is replaced by a block grant scheme, states will receive a fixed amount of federal funds annually based on past costs instead of a percentage of actual costs incurred. With a cap on federal spending regardless of need, states would be left unprotected if costs were to go up because of a public health crisis (think Zika or the opiod epidemic), the rising costs associated with an aging population, or the impact of a natural or manmade disaster.

The repeal of the ACA without a comparable replacement would put at risk all the gains we’ve made in expanding health coverage to a greater share of people and in strengthening the nation’s health care system. Let us hope that the enormous outpouring of support from around the country for maintaining the provisions of the ACA and the voices of concern raised about the enormous human and economic costs associated with reversing it will be heard in Washington in the days ahead.

For more information on advocacy to preserve Medicaid, please find up-to-the minute analyses from Justice in Aging, Community Catalyst, the Kaiser Family Foundation, the National Health Law Program, and Families USA. On related efforts to preserve Medicare, please visit the websites of the Medicare Rights Center, AARP, and the Center for Medicare Advocacy.