On its 12th anniversary, it’s time to make the Affordable Care Act work for more people

By Matthew Snider, Senior Policy Analyst, Health Policy Project, UnidosUS

Twelve years ago, Congress passed the Affordable Care Act (ACA), one of the largest expansions of health coverage in American history. The law also represents one of the greatest advancements in health equity, by cutting the uninsured rate for Latino children nearly in half and reducing the overall uninsured rate for Latinos from a high of 32% in 2010 to 18.9% in 2017. Through Medicaid expansion  (one of the law’s key levers for reaching more low and moderate income people) more than three million Latinos received affordable health coverage. Even prior to recent changes, the law also had the potential to reach even more people, including 1.9 million uninsured Latinos who were eligible for Marketplace financial assistance to lower their premiums to $0. Since the law’s implementation, UnidosUS has consistently worked to ensure everyone eligible enrolls in affordable coverage.

At the same time, the ACA fell short in several important ways.

• While individuals with certain deferred enforcement immigration statuses are eligible for Marketplace coverage, those with Deferred Action for Childhood Arrivals (DACA) status are blocked from enrolling in Marketplace coverage (along with all undocumented immigrants). The exclusion of many immigrants contributes significantly to the persistently high Latino uninsured rate. Non-citizen Hispanics have higher uninsured rates than any other group of non-citizens, regardless of income. More than 600,000 people have DACA status—the vast majority of which are Latino—and nearly one-third of which are “essential workers.”
• When the Supreme Court ruled that the ACA’s Medicaid expansion provision was merely an option for states, rather than a requirement, many conservative states refused to expand for largely partisan reasons. The failure to expand Medicaid in the 12 remaining states has left more than four million Americans cut off from Medicaid including more than two million with no viable pathway to affordable coverage at all (in the so-called “coverage gap”).
• Even with the ACA, affordability of coverage remained a challenge for many. This caused many households to avoid Marketplace coverage they were eligible for, in part due to high premiums and deductibles.

COVID-19 is revealing and exploiting the existing shortcomings in our health system, with Latinos and other communities of color more likely to contract, be hospitalized, or die from the virus than were non-Hispanic whites. The pandemic struck at a moment when progress made under the ACA was already reversing course for Latinos—with Latino uninsured rates beginning to rise after a decade of progress. In non-expansion states the uninsured rate for Latino parents and children was not only higher than in Medicaid expansion states, but also accelerating faster. DACA recipients were struggling with the stress and anxiety driven by uncertainty about the program’s future, and the Trump administration’s revised public charge rule was projected to lead to significant disenrollment of eligible individuals in mixed-status households.

As Congress and the Biden administration consider the necessary steps to emerge stronger from the pandemic, it’s time to make the ACA work even better for more people. There are two actions both Congress and President Biden can take immediately to reach this goal and advance health equity.

Congress should:

• Extend the American Rescue Plan Act’s (ARPA) advanced premium tax credit (APTC) improvements. These improvements help put affordable health coverage within reach for more than three million Latinos and helped 5.8 million new individuals afford After they became available during last year’s Special Enrollment Period, a higher percentage of Latinos enrolled in coverage than the same period the year before (19% vs. 16%). With the end of the Medicaid disenrollment freeze, newly uninsured Latinos will look to other avenues for affordable health coverage, but the ARPA provisions currently expire after this year. Extending the APTC changes is one of the most straightforward improvements to the ACA that Congress can make.
• Close the Medicaid coverage gap. More than 610,000 Latinos are unable to afford quality health coverage because states like Texas and Florida refuse to expand Medicaid. Two-thirds of individuals living in the coverage gap are people of color. As we wait for states to expand, coverage rates for Latinos living in these states is moving the wrong direction. Latinos can’t wait, particularly when facing worsened mental health and the risks of long COVID even after the pandemic is behind us.

President Biden should:

• Expand eligibility for the Marketplace to those with DACA status. While many DACA recipients are “essential workers,” like many Latinos, they often work in jobs that do not offer job-based health insurance. In 2019, only about half of DACA recipients had health insurance. The unjust exclusion of DACA recipients from either purchasing coverage on the Marketplace or qualifying for financial assistance is an arbitrary barrier not applicable to other immigrants with deferred enforcement statuses. The Department of Health and Human Services should clarify ACA eligibility for people granted DACA status and clarify that they are “lawfully present” for the purposes of Medicaid and the Children’s Health Insurance Program (CHIP).
• Strengthen civil rights protections through Section 1557 rulemaking that protects access for limited English proficient populations. President Trump weakened civil rights protections under Section 1557 of the ACA through rulemaking. This jeopardized access for many individuals, including those with limited English proficiency. Robust civil rights protections are an essential element of an equitable health system. COVID-19 only further demonstrated the need for access to key health information in a language every person understands.