Editor’s note: This commentary is by Audree Frey, of Underhill, who is a student in the master of public health program at the University of Vermont.
[F]ive years after most of the provisions in the Patient Protection and Affordable Care Act (ACA) came into effect, the health care law is still a political hot button issue that has been embroiled in legal challenges since President Barack Obama signed it into law back in 2010. Republicans have tried multiple times – and so far have failed – to repeal the law. The U.S. Supreme Court has upheld the ACA in two previous challenges, first in 2012 and again in 2015, and it now appears to be headed for a third review by the high court. A Dec. 14, 2018, ruling by a U.S. district judge in Fort Worth, Texas, sided with a coalition of 20 states challenging the constitutionality of the law due to the elimination of the individual mandate by the Republicans’ signature tax reform bill in 2017.
In December, Vermont joined a multi-state coalition seeking an immediate appeal of the Texas decision, which is likely to result in the Supreme Court weighing in on the ACA for the third time. In the meanwhile, the Vermont House has introduced legislation (H.129) this session that calls for universal primary health care to be in place in the state by 2023. This has been a longstanding goal for many Vermonters, as evidenced by our failed attempt in 2011-2014 and stalled legislation last year, and was the ultimate intent of the ACA.
In the midst of this uncertainty, it is worth reviewing the impact of the ACA, its strengths and weaknesses, and possible next steps towards its primary goal of providing universal affordable health care to all Americans.
The ACA has enabled the United States to address long-standing issues plaguing our health care system, achieving great progress in the areas of access, affordability, and quality of care. According to a 2016 report in the Journal of the American Medical Association, there has been a 43 percent decline in the uninsured rate in the U.S. since the ACA became law as a result of the law’s reforms. The report also cited studies showing improvements in health care access, with an estimated 5.5 percent fewer adults unable to afford care; financial security, with a nearly $1,000 per-person reduction in debts being sent to collections for those gaining access to Medicaid; and health outcomes, with 3.4 percent fewer adults reporting their health status as fair or poor. According to the Commonwealth Fund, a nonprofit organization supporting independent research on health care issues and offering grants to improve health care practice and policy, the number of American adults who reported being unable to get necessary health care and prescriptions due to cost fell by 17 million between 2012 and 2016.
Despite the impressive gains listed above, the ACA is far from perfect, and there are calls for major refinements from both conservatives and liberals alike, with the former arguing that it went too far and the latter that it did not go far enough. I align with the latter argument, held by progressive voters in Vermont and nationwide, that the ACA did not go far enough, as it did not achieve the intended goal of universal health care coverage, and the coverage that was made available through the law was not equitable (the lowest-income people gained coverage through Medicaid expansion, which, while preferable to not having insurance at all, is a far cry from the comprehensive coverage offered by most employer-provided plans). Republican efforts to repeal the law have failed thus far, and from a public health perspective this is certainly not the desired approach. Instead, we should build on the successes of the ACA by moving toward options like Medicare for All, as proposed by Vermont Sen. Bernie Sanders among others, which would take us in the direction of achieving universal, equitable coverage.
Of course, paying for such a system is always a point of contention, and that is a major hurdle currently facing H.129. However, as the bill’s lead sponsor, Progressive Rep. Brian Cina of Burlington told VTDigger earlier this month, “By investing in universal primary care, we can improve population health and save lives and save money.” Numerous studies have shown that this could be the case at the federal level as well, with the administrative savings of enacting a Medicare-like one-payer system offsetting the costs of providing comprehensive, equitable coverage to all U.S. residents.
I applaud our progressive Vermont legislators for renewing the call for universal primary health care in our state. Perhaps this time around we can provide a model for the rest of the nation to follow.
