The constitutionality of the Affordable Care Act (ACA) is being challenged in the California v. Texas Supreme Court case. Originally referred to as Texas v. United States, the case was filed in February of 2018 with the intent of striking down the individual mandate of the ACA, which requires most residents of the United States to have health insurance. The representatives who filed this lawsuit argue that the individual mandate cannot be separated from the ACA, and that the law should be struck down in its entirety.

Eighteen attorneys general and governors, two private individuals, and the Trump administration are arguing to repeal the ACA, while 21 attorneys general and the House are defending it. On November 10, 2020, the Supreme Court heard oral arguments, and the ruling is expected sometime in spring or summer of 2021. Because millions of people with diabetes depend on the healthcare benefits provided by the ACA, we remain hopeful that the majority of the ACA will be preserved even if the individual mandate is repealed. 

The Affordable Care Act and what many people with diabetes could lose

Passed in 2010, the ACA significantly expanded healthcare coverage in the US and outlawed several forms of health discrimination by insurance companies. If it were repealed, nearly 20 million Americans would become uninsured – and likely even more due to the recent economic impact of the COVID-19 pandemic. Shawn Dhanak, who has type 1 diabetes, wrote an article in 2017 about his experience with insurance before and after the enactment of the ACA. He wrote, “comprehensive, affordable coverage was simply unattainable in the pre-ACA world for someone out of work or underemployed but in need of treatment for a pre-existing condition.” The following are some examples of how the ACA helps people with diabetes in particular.

• Pre-existing conditions: Before the ACA, people with diabetes could be denied insurance or forced to pay higher premiums because they have a pre-existing condition. The ACA outlawed private insurers from discriminating against the 54 million non-elderly people with pre-existing conditions in the US. This estimate from the Kaiser Family Foundation refers to the number of people with “declinable” pre-existing conditions that insurance companies routinely did not cover before the ACA. However, it is estimated that well over 100 million non-elderly people in the US have a pre-existing condition.
• Medicaid Expansion: The ACA increased the eligibility for Medicaid coverage, and since the ACA was passed, 39 states have opted to expand Medicaid. According to the Urban Institute, states that expanded Medicaid would see a 92% increase in the number of people without insurance if the ACA was repealed, leaving a total of 29.6 million people uninsured in these states. For states that did not expand Medicaid, the number of people without insurance would increase by 38%, leaving a total of 20.6 million people uninsured in these states. Look here for more information on how Medicaid helps people with diabetes.
• Dependent Coverage: The ACA requires private group and non-group health plans to cover dependents until they are 26. Millions of young adults gained coverage, and many young people with diabetes are able to maintain access to quality healthcare. Look here for information about aging out of family insurance plans.
• Free Preventive Services: The ACA requires that private insurers provide free preventive services. Related to diabetes, this includes type 2 diabetes screening, nutrition counseling, and blood pressure testing. There are also free preventive diabetes-related services for Medicare beneficiaries (NCBI). This 2016 study estimates that approximately 2.3 million of the 4.6 million people with undiagnosed type 2 diabetes aged 18-64 may have gained access to free preventive care under the ACA. ADA estimates that over 7 million people have undiagnosed diabetes so it is likely that many more could benefit from these free preventive services.

We need the ACA today more than ever before

A recent report from The Commonwealth Fund, “U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability,” recorded alarming rates of uninsured and underinsured younger Americans (age 19-64) in the first half of 2020. As of June, an estimated 14.6 million Americans lost their insurance from COVID-19 related job loss. More specifically, a stunning 18% of people with diabetes were unemployed in July, according to estimates from dQ&A and ADA. At a time when access to high-quality and affordable healthcare is more important than ever, startling numbers of Americans have been left without adequate health insurance.

According to the Commonwealth Fund report, 43.4% of younger adults in the US were inadequately insured in the first half of 2020. More specifically, 12.5% of younger adults were uninsured altogether, 9.5% had a gap in insurance coverage in the past year, and 21.3% were underinsured. The rates of the uninsured were highest among Black and Latinx individuals at 24% and 40%, respectively, and among low-income populations.

As described above, 21.3% of younger adults across the US were underinsured, meaning they have unaffordable health plans with high deductibles and/or premiums. Even among the 122 million people who have employer-sponsored insurance, one in four are estimated to be underinsured, according to the Commonwealth Fund. Similar to those who are uninsured, people who are underinsured face financial barriers to consistent and quality healthcare.

The insurance crisis in America did not start with the COVID-19 pandemic. The Commonwealth Fund estimates that there were 30 million uninsured people (age 19-64) and more than 40 million underinsured people when the pandemic began. Even with the ACA, millions still lack adequate health coverage. Policymakers need to be finding ways to make health insurance more accessible and affordable instead of repealing vital healthcare legislation and making our health systems worse.

Looking to the future

As the numbers of uninsured and underinsured Americans continue to rise because of the COVID-19 pandemic, the ACA is more important than ever. Without health insurance, people with diabetes almost certainly face poorer health outcomes and related financial challenges. People who do not have the resources to manage their diabetes can experience diabetes-related complications such as heart disease, kidney disease, and amputations, and today people with diabetes are also at a higher risk for more severe COVID-19 health complications.

For far too many people, California v. Texas threatens the basic human right of quality and affordable healthcare. Any efforts to eliminate protections for pre-existing conditions would have severe consequences for people with diabetes. We call on the US government to counter these efforts and ensure that everyone has access to the healthcare they need regardless of their health status.