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133 million Americans have preexisting conditions. Here's what would happen if the ACA is repealed

The potential repeal of the Affordable Care Act was discussed during the first presidential debate of 2020 between President Donald Trump and former Vice President Joe Biden.

A demonstrator holds a sign in support of President Barack Obama's health-care law, Obamacare, in front of the U.S. Supreme Court in Washington, on Wednesday, March 4, 2015.
Andrew Harrer | Bloomberg | Getty Images

When President Donald Trump and former Vice President Joe Biden met for the first of three presidential debates Tuesday night, health care and the appeal of the Affordable Care Act, otherwise known as the ACA or "Obamacare," was one of the first issues they addressed.

The topic arose after moderator Chris Wallace asked both men about the confirmation of Amy Coney Barrett, the proposed replacement for Supreme Court Justice Ruth Bader Ginsburg, who died in September. If confirmed, one of the first cases Barrett would rule on could decide the future of the Affordable Care Act, which, among other provisions, ensures that Americans with preexisting conditions cannot be denied coverage.

During the debate, President Trump said, "Obamacare is no good," and that his own health-care plan, which he has yet to unveil, would save Americans money. Former Vice President Biden countered that the president has "no plan for health care" and since he has been in power "hasn't lowered health-care costs." 

Here is how repealing the Affordable Care Act would likely affect Americans, and what President Trump has done during his term in regards to health care. 

The impact of an Affordable Care Act repeal

More than 11 million people bought health insurance through the ACA marketplaces during 2019, according to a Kaiser Family Foundation analysis. And 12 million low-income adults have Medicaid due to the ACA, which let states opt-in to expand the program. Thirty-five states, plus the District of Columbia, have done so.

Those 23 million people could lose health coverage if Obamacare is repealed and there is no alternative put in place.

About 133 million people with preexisting conditions would see premiums go up or be denied coverage, according to a 2017 report by the Department of Health & Human Services. Of those 133 million, an estimated 54 million Americans have conditions that would allow insurers to deny them coverage if the ACA were not in effect, according to a 2019 Kaiser Family Foundation analysis.

Should the Supreme Court rule that the ACA is invalid, there would no longer be coverage for preexisting conditions, says physician-turned-financial-advisor Carolyn McClanahan, director of financial planning at Life Planning Partners in Jacksonville, Florida. 

"Costs would go up for unhealthy people, but may go down for healthy people," she says. "There are 100 million people with preexisting conditions and they will definitely see their costs go up." 

There are 100 million people with preexisting conditions and they will definitely see their costs go up.
Carolyn McClanahan
financial advisor

The coronavirus pandemic makes this issue particularly relevant, since the ACA keeps insurers from discriminating against those who contracted Covid-19 or are at a high risk for contracting it, according to a report by the Kaiser Family Foundation. If the ACA is repealed, the report notes, "someone who applies for medically underwritten health insurance while sick — or after having been sick — with Covid-19 might be turned down, charged more, or offered a plan that excludes coverage for Covid-19 or related symptoms." 

Repealing Obamacare would have "catastrophic impacts" on peoples' ability to afford health care, Eliot Fishman, policy director at Families USA, told Grow. This is especially true for middle-class families. "People with middle incomes, up to 400% of the federal poverty level, who are eligible for subsidies in the nongroup and small group markets would lose those subsidies," he says. 

Obamacare also allowed children to stay on their parents' insurance until they are 26 years old. That would end with the repeal of the ACA, meaning that another 2 million adults could feel the effects. 

"The quality of coverage people are getting could go down quite a bit," Ben Sommers, professor of health policy and economics at Harvard University, told CNBC last year. And overturning the law without a replacement in place could create "confusion and chaos," he said, since the ACA affects so many elements of the health-care system. 

What a Biden presidency could mean for health care

"What's at stake here, as the president has made it clear, he wants to get rid of the Affordable Care Act," Biden said at the debate Tuesday. "He's been running on that. He ran on that and he has been governing on that." 

Under Biden's proposed plan, the cost of ACA marketplace coverage would go down for almost all Americans, according to a report by the Kaiser Family Foundation. More than 12 million people could pay less for insurance by switching from their employer-based insurance to a plan through the ACA Marketplace, while federal spending would increase, the report says. 

Biden's plan could cover all legally present U.S. residents, according to a 2020 report by the Urban Institute, which studied the potential effects of a plan similar to the former vice president's. Still, 6.6 million undocumented immigrants would be uninsured. 

What Trump has accomplished on health care 

"Trump has done some executive orders, but he's done nothing substantive," McClanahan says. "He definitely hasn't done anything to protect preexisting conditions or lower health-care costs."

Republican leaders say the administration is trying to serve those with preexisting conditions. Last week, Trump signed executive orders related to preexisting conditions and aiming to prevent surprise medical bills. These are part of what the president calls his "America First" health-care plan, which involves urging Congress to act. 

"Every Republican agrees we're going to protect preexisting conditions," Senator Ted Cruz said Monday on "Squawk Box."

However, executive orders don't allocate money, McClanahan says, so unless Congress does act, the president's power is limited: "He can't spend money through an executive order, so he can't really do anything that costs money." 

His actions also might be too little too late, since "they look like pandering to try to win this election," she says. "If he was serious about fixing health care, he would have done this two years ago." 

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