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Katelyn Watters

Professor Jennifer Santiago

UWRT 1102-027

16 March 2017

Repealing the Affordable Care Act: Effects on Vulnerable Populations

Since the Affordable Care Act's implementation in 2010, it has been at the dead center of

nationwide controversy. While studies show that the Affordable Care Act, commonly referred to

as the ACA, is supported by over half of Americans, the majority of Republican politicians have

advocated for its repeal since the day of its debut (Dalen et al. 807). The ACAs primary goal is

to improve the health of Americans by increasing their access to health insurance (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concerning, often proposing the question: if the ACA were repealed, how would this impact the

American public? Many of these newly insured Americans are vulnerable, as they are oftentimes

economically disadvantaged, burdened with chronic illnesses, or a part of a racial or ethnic group

(Steinbrook, et al.). A repeal of the Affordable Care Act would have a significantly negative

impact on Americas vulnerable populations, particularly low-income individuals, as they would

lose their access to readily available affordable health care.

The Affordable Care Act is an act that was passed March of 2010 that successfully

extends affordable health coverage to millions of previously uninsured Americans, mainly due to

its provisions for state-based Medicaid expansion and subsidies to assist middle and lower

income individuals in purchasing private health insurance (Affordable Care Act History). An idea
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to overhaul the American health care system to implement a nationwide health system is hardly

new, it just was not successfully executed until former President Barack Obamas time in office

(Affordable Care Act History). The ACA includes a mandate, called the individual shared

responsibility payment, that requires Americans to obtain health coverage, or 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 (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). 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 (Eibner and Price). 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).

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).

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
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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

objectives when adopted into law (Dalen et al. 807).

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

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% FPL or less who are under the age of 65 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 ability to provide healthcare 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
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uncompensated care can instead be invested in efforts to provide improved care and preventative

treatment, leading to better overall health outcomes (Hoadley and Searing).

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

(Dalen et al. 808). 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 voting no (Dalen, et al. 808). Many opponents of the ACA argue that the individual

mandate is unconstitutional, the ACA has put insurance premiums on the rise, and that it is not

the sole responsibility of the federal government to ensure that Americans have access to

healthcare (Dalen, et al. 809). While there are many facets to the effects 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 in America (Dalen, et al. 808). More than 10 million individuals

gained health insurance in 2014 alone that would have otherwise remained uninsured due to the

Affordable Care Act (Dalen, et al. 808).

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 is found that after the ACA was fully implemented in 2014, its overall

approval ratings decreased by six percent from 2013, with fifty-five percent of Americans being

opposed to the individual mandate (Dalen et al. 808-809). It was also found that in 2014, only

forty-five percent of Americans believed that it was the responsibility of the government to

ensure its citizens had access to health coverage (Dalen et al. 808). With this information in

mind, it poses a pertinent question: If the ACA has had such success in providing affordable
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coverage to uninsured Americans as the evidence suggests, where is all this opposition stemming

from? It is likely that a portion of the opposition comes from heavy media influences (Dalen et

al. 809). The study also details that sixty percent of Americans reported that the information they

had about the ACA was delivered to them via the television (Dalen et al. 808). This is alarming,

as it is widely recognized that numerous media outlets have their own personal, political, and

financial agendas to push. In 2014, ninety-four percent of the $445 million spent on television

advertising for the ACA was used to display negative images and information (Dalen, et al. 809).

General disapproval in the ACA by the public due to misinformed media influences 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 the ACA (Dalen et al. 810).

Without Americans being exposed to the legitimate effects of the ACA through reliable facts and

statistics, it is unlikely that America will achieve universal health care at any point in the near

future (Dalen et al. 810).

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 added 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

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). For

the purposes of this discussion, low-income individuals will be further subdivided into the

unemployed, low income women, and the homeless.

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The Affordable Care Act has played a significant role in assisting unemployed individuals

in obtaining affordable coverage. 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 an pre-existing condition (Health

Insurance). However, since the implementation of the ACA, when an individual purchases

insurance from the individual market, occasionally referred to as the Health Insurance

Marketplace, insurance 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 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 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 Saltzman). According to a COMPARE-based analysis, a repeal would create a cessation in

tax 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
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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 (Eibner

and Saltzman), leading to a lack of necessary health care, higher uncompensated costs for

hospitals, and overall poorer health outcomes for these 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). These factors combine to result in

adverse health outcomes for both the mother and child, as well as poorer social and economic

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 overall lack of awareness of the accessibility (Fox and Barfield). If the Affordable

Care Act were to be repealed, it would reverse the improvements that have been made by
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decreasing accessibility for those dependent on these LARC methods, in turn likely raising the

unintended pregnancy rates in America.

The homeless are another vulnerable, low-income population that would be heavily

impacted by a repeal, as 1.2 million Americans face homelessness each year (Fryling, et al.).

Homelessness is often defined as the absence of stable housing for more than two months,

examples include but are not limited to sleeping in a car, 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 (Fryling, et al.). 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, a 30-question survey that assessed access to

communication, awareness of the ACA, insurance status, and obstacles when attempting to

obtain coverage 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 reported 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
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instilled changes in the healthcare system 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 would result in higher uncompensated ED costs due to the inability

of homeless populations to see primary care physicians (Fryling, et al.).

With an estimated 15.2% of the population living below the 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. Even if not at first, a repeal

would eventually result in higher long-term costs for virtually all parties involved, as well as

resulting poorer health outcomes and life expectancy rates of vulnerable populations. As a

nation, Americans must work together to improve the welfare of all citizens.

Works Cited

Affordable Care Act History. Affordable Health California,

Basu, Rituparna. The Broken State of American Health Insurance Prior to the

Affordable Care Act: A Market Rife with Government Distortion.,

Ayn Rand Institute,

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Brandon, W. P. "Medicaid Transformed: Why ACA Opponents Should Keep Expanded

Medicaid." Journal of Health Care for the Poor and Underserved, vol. 23 no. 4, 2012.

Project MUSE, doi:10.1353/hpu.2012.0176

Bureau, US Census. Age and Sex of All People, Family Members and Unrelated

Individuals Iterated by Income-to-Poverty Ratio and Race., US Department

of Commerce, 18 Apr. 2015,



Carroll, Aaron E. A Look at Republican Plans for Repealing and Replacing

Obamacare. The Jama Forum, vol. 317, no. 4, 2017. Jama,


Dalen, James E., et al. Why Do So Many Americans Oppose the Affordable Care Act?

The American Journal of Medicine, vol. 128, no. 8, 2015, pp. 807810., doi:


Eibner, Christine, and Carter C. Price. How Would Eliminating the Individual Mandate

Affect Health Coverage and Premium Costs? RAND Corporation, 15 Feb. 2012,

Eibner, Christine, and Evan Saltzman. Assessing Alternative Modifications to the Affordable

Care Act: Impact on Individual Market Premiums and Insurance Coverage. Rand Health

Quarterly vol. 4, no. 4, 2015.,

Federal Poverty Level Guidelines. Obamacare Facts,

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Fox, Jared, and Wanda Barfield. Decreasing Unintended Pregnancy Opportunities

Created by the Affordable Care Act. The Journal of the American Medical Association,

vol. 316, no. 8, 2016, pp. 12., doi: 10.1001/jama.2016.8800.

Fryling, Lauren R., Peter Mazanec, and Robert M. Rodriguez. Homeless Persons

Barriers to Acquiring Health Insurance through the Affordable Care Act. The Journal of

emergency medicine, vol. 49, no. 5, 2015., https://www-ncbi-nlm-nih-



Health Coverage Grows Under Affordable Care Act. RAND Corporation, 16 May


Health Insurance Coverage of the Total Population. Health Insurance Coverage of the

Total Population, Kaiser Family Foundation,



Henshaw, Stanley K. Unintended Pregnancy in the United States. Family Planning

Perspectives, vol. 30, no. 1, 1998, pp. 2446. JSTOR,

Hoadley, Jack and Adam Searing. The Ripple Effects of Medicaid Expansion., 7 June 2016,


Questions and Answers on the Premium Tax Credit.,

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State Unemployment Rates in 2010 : The Economics Daily. U.S. Bureau of Labor Statistics,

U.S. Bureau of Labor Statistics,

Steinbrook, Robert, et al. JAMA Intern Medicine. JAMA Intern Medicine, 20 Jan. 2017.,

Winetrobe, H., et al. Health Insurance Coverage and Healthcare Utilization among Homeless

Young Adults in Venice, CA. Journal of Public Health, vol. 38, no. 1, 2015, pp. 147

155., doi:10.1093/pubmed/fdv001.