“The Affordable Care Act and Low-Income Americans”
Timothy S. Jost
Robert L. Willett Family Professor of Law
Washington and Lee University School of Law
Delivered on Aug. 5, 2014 at the Virginia Military Institute for the SHECP Teaching Symposium

Professor Jost has kindly provided us with a manuscript of his talk at the symposium. Teachers and students may use it for information and cite the source of their information about the Affordable Care Act and poverty, but please do not quote or cite a direct paraphrase. You are responsible for how you use and interpret the undocumented manuscript.

Tim Jost

Tim Jost

It is hard to be poor in the United States. My wife works has worked for some time with ex-offenders. These are often people who were locked up on minor drug charges. Sometimes more serious offenses are involved, but rarely violent crimes. Often, they have been imprisoned for debt, for failure to pay child support or fines. Often they are re-imprisoned for minor probation violations.

What is striking is how hard it is for them to break back into society. Often imprisonment or failure to pay fines means loss of a driver’s license. This makes it difficult if not impossible to get and keep a job in western Virginia. Loss of a driver’s license can also make it difficult to prove identity, making it difficult for ex-offenders to, for example, open a bank account or cash a check. Employers are also, of course, reluctant to hire ex-offenders. Many applications for low-wage jobs are handled online. An employer need never explicitly reject an application for ex-offender status; the employer can simply fail to acknowledge it.

One doesn’t need to be imprisoned, however, to fall into the poverty trap. Falling behind on rent may result in eviction. The eviction usually shows up on the evicted person’s credit rating. Rental applications are now often handled online rather than in person. An individual with an eviction on his or her record may never even receive a response to an application. If the individual was behind on utilities as well, restarting gas or electric service may require paying up arrearages.

A minimum wage job may not pay enough to live on, particularly if it is part-time. If income cannot be stretched to the end of a pay period, an individual may need to resort to car-title or, in some states, payday lenders. Interest rates on these loans may equal an annual rate of 400 percent. Turnover on low-wage jobs is also high, and an individual who has to miss work because childcare arrangements fall through or a car breaks down can find him or herself unemployed.

Perhaps the worst thing that can happen to a poor individual, however, is to get sick. In all other developed countries, illness is regarded as a natural consequence of the human condition and a burden to be borne by society. Just as we believe everyone should be entitled to an elementary and secondary education, and the opportunity afforded by an education, all other developed countries believe that no one should lose out in life because he or she cannot afford health care. The approaches that other countries take to financing health care vary greatly, but each of them ensures that individuals with health-care needs get at least access to hospital and physician services and usually access to other basic medical services as well, with no cost or with affordable cost-sharing.

As you all know, in the United States we have no comprehensive national health insurance program. We have rather had a patchwork of programs that cover some people with some conditions on some occasions. Most working age Americans, including many lower income Americans, receive health coverage through their employment. Although most of us don’t think about it much, this coverage is heavily subsidized by the federal and state governments. Income that is spent on health insurance is not subject to income tax, Social Security Tax, Medicare tax, federal unemployment tax, or state income tax. And the subsidy gets greater as income increases. A high income executive with a Cadillac plan can get over half of it paid for by the federal government. Low-wage workers not offered health insurance by their employers, get no benefit at all. Neither do the unemployed and uninsured.

We also have government programs. We have Medicare, a federal program, for individuals over age 65 and the long-term disabled. We have Medicaid, which helps elderly and disabled people with costs that are not covered by Medicare and also covers poor children, and sometimes their parents. The CHIP program covers children with incomes between 100 and 200 percent of poverty, and in some states with higher incomes. We have the Indian Health Service for Native Americans, the Veteran’s Administration that helps some Veterans with some problems, and Ryan White programs for people with AIDS.

Some localities have community health centers that provide primary care to individuals for payment on a sliding scale. Some communities, including Lexington, have free clinics that provide care to some people for free. Some drug companies offer discount programs for some drugs. Tax exempt hospitals offer financial assistance to low-income patients, although discounts are often reductions from the full charge of the hospital, which is far above what the hospitals are paid by insurers and government programs.

Finally, the Emergency Medical Treatment and Active Labor Act provides that hospitals that receive Medicare and have emergency rooms must screen and stabilize individuals who show up at the emergency room regardless of their ability to pay. EMTALA is often misunderstood, although I think poor people understand it better than others. It does not require hospitals to provide services for nothing. Unless individuals are insured, covered by a government program, or determined eligible for financial assistance from the hospital, they must pay the full cost of the emergency care they receive, and emergency room care is very expensive. Moreover, it only requires hospitals to provide care in emergencies. If people need maintenance care for chronic conditions or ongoing treatment, such as chemotherapy, it is not covered.

What we have is a series of tattered and torn safety nets, and many people fall through the cracks.

What are the consequences of this patch work of health-care assistance? First, individuals often defer care and treatment that they need because they cannot afford it. This may mean not seeing a doctor when they are ill or injured or not following up with recommended tests. It may mean not filling prescriptions for needed medications, including maintenance medications, or splitting pills to make them last longer. Deferring or foregoing care may mean lower productivity, increased absenteeism, or job loss. It may mean allowing a condition that could have been treated successfully early on to deteriorate until it becomes much more costly to treat, or simply untreatable. It also means feeling miserable much of the time.

But poor people who seek treatment may not be able to get it. Many healthcare providers now demand payment up front for non-emergency care, or will not accept the uninsured as patients. If they get treatment, however, they will face medical debt. Medical debt can mean debt owed directly to providers, but often means credit card debt, as many providers insist on payment by credit card. People with medical debt they cannot pay must cut other necessary expenses and often must endure harassment from collection agencies, garnishments, and ruined credit ratings, which in turn makes getting housing or other necessities more difficult. Many Americans simply give up. Medical debt is a leading cause of bankruptcy in the U.S.

Whether poor people forego medical care or seek it and then cannot pay for it, their stress levels inevitably increase. High stress in turn results in its own physical and mental complications. It can result in domestic violence or simply in a tense environment for raising children. This in turn may interfere with education and socialization.

So what does the ACA do to address these problems? First, and most importantly, it expands Medicaid. The roots of Medicaid go back to 1935, when Congress passed the first Social Security Act. That statute, which established a contributory federal pension system for the elderly that has come to be known as Social Security, also created public assistance programs for the elderly, the blind, and families with dependent children. These were programs under which the federal government made grants to the states, which in turn provided assistance to needy persons. Public assistance for the disabled followed later.

In 1950 Congress made limited funds available to the states for “vendor payments” for medical care for people receiving financial assistance. In 1960 the Kerr-Mills act extended medical coverage for the elderly, as well as creating a program for the medically needy—elderly persons who had income above public assistance levels but had medical spending obligations that consumed their income.

In 1965, Congress created Medicaid, which provided grants to the states for medical care for persons who qualified for public assistance under the preexisting programs for the elderly, disabled, blind, and families with dependent children. The scope of Medicaid coverage has steadily expanded over the decades since 1965: to elderly, blind, and disabled individuals who receive federal supplemental security income, pregnant women, children in families with incomes up to 100 percent of the poverty level, women with breast cancer, and dozens of other small categories of persons who cannot afford health care. In the interim, the state cash assistance programs on which Medicaid was originally based were repealed, delinking Medicaid from cash welfare programs.

The ACA completed the transformation of Medicaid from a simple adjunct to state public welfare programs to a program providing health insurance for all poor Americans. Although the Supreme Court in the ACA case described this change as a radical change in the nature of the program, in fact it was a natural extension of Medicaid as the program had evolved over the years.

By far the best known change the ACA made in the Medicaid program was to expand its coverage by 2014 to all adults under age 65, who are not pregnant or covered by Medicare, and to all children with household incomes not exceeding 133 percent of the poverty level. In fact, the law requires that state Medicaid programs disregard the first 5 percentage points of income, so the eligibility level is really 138 percent of poverty. The Federal Medical Assistance Percentage, normally varying from 50 to 80 percent of state Medicaid expenditures for services, was increased for this group to 100 percent for 2014, 2015 and 2016, 95% for 2017, 94% for 2018, 93% for 2019, and 90% for 2020 and thereafter. States that already cover the expansion population will receive assistance at lower levels initially, but gradually grow to these levels. The reconciliation bill also increased Medicaid funding for territories.

The law not only changed Medicaid eligibility requirements; it also altered the benefit package. Medicaid programs need not cover all of the same services for the expansion population that they do for other recipients, but must rather provide benchmark or benchmark equivalent coverage for this population. Coverage must include at least the minimum essential benefits required for private plans under the reforms and, with limited exceptions, meet mental health parity requirements. In fact, regulations implementing the ACA require states to designate benchmark plans to identify coverage for the individual and small group market, which are usually one of the most popular small group plans in the state. Medicaid benchmark coverage for the expansion population is usually similar, although states can use different benchmarks for coverage than the benchmark the state uses for private plans.

States were allowed to cover the expansion population before 2014, but had to make lower-income subclasses eligible before higher-income subclasses. A number of states did so, establishing programs that covered almost a million people. States were also generally obligated to maintain pre-existing Medicaid eligibility standards from the date of enactment in 2010 until an exchange was established in the state, and to maintain eligibility standards for children through 2019. Beginning January 1, 2014, states were allowed to extend optional coverage to adults with income above the 133 percent of poverty level if their programs met specified requirements.

The ACA also changed the method states use for calculating income eligibility for many recipients. The ACA requires the states to use modified adjusted gross income to determine eligibility for Medicaid as of January 1, 2014, without income or expense disregards and without asset tests. This standard does not apply to individuals eligible for Medicaid because of their eligibility for Supplemental Security Income or other benefits, persons who are 65 or older, the medically needy, or individuals eligible for Medicare cost-sharing benefits. These rules also do not apply for determining eligibility for receiving nursing facility services or home and community-based care services.

The ACA also extended the children’s health insurance program, or CHIP to September 2015. CHIP covers children in families with incomes above 138% of the poverty level, in some states up to 400% of poverty. It currently covers about 8 million children, including many children of parents who are themselves covered through the exchanges with premium tax credits.

Beginning in October 2015, the ACA would increase the federal medical assistance percentage for CHIP by 23 percentage points until September 30, 2019. That requirement, however, depends on Congress extending the CHIP Program beyond September 2015, when it would otherwise expire. States may not put into effect more restrictive eligibility standards prior to September 30, 2019 than those in effect at the date of the enactment of this act. If state CHIP fund allotments are not adequate to provide coverage for eligible children, a state must make sure that children who are not covered are provided coverage through an exchange. Beginning in January 1, 2014, CHIP eligibility is determined using modified adjusted gross income. Children who lose Medicaid eligibility because of the elimination of income disregards will be eligible for CHIP.

There is a serious debate at this point as to whether CHIP should be extended beyond 2015. Some argue that children in CHIP should be moved to the exchanges where they would be covered under the same coverage as their parents, using the same providers. On the other hand, others contend that CHIP is a well-established program that works well and meets the needs of children and should be maintained until we are certain that private insurance coverage through the exchanges is fully functional.

The ACA increased Medicaid payments for family and general internal medicine practitioners and for pediatricians providing primary care services to 100 percent of Medicare payment levels for 2013 and 2014 with a 100 percent federal match. Medicaid expansions mean little if there are no practitioners to care for Medicaid recipients, so this provision could play a vital role in making Medicaid work. Unfortunately, that provision was limited to two years and was slow in getting implemented.

The ACA also attempted to simplify the enrollment process for Medicaid and CHIP, although the simplification has not yet been fully realized in a number of states. New enrollment simplifications allow Medicaid and CHIP enrollment via the exchanges through the no-wrong door approach. Whether individuals apply through the exchange or through a state Medicaid agency, they should be enrolled in the correct program. This program is not yet fully functional, but progress is being made.

The law also significantly allows hospitals to make presumptive eligibility determinations for Medicaid. This provision is very important because it effectively makes Medicaid a catastrophic health insurance program for all people who are eligible. If they are really sick and show up at a hospital, even if they are not enrolled, the hospital can enroll them for immediate coverage.

Medicaid benefits are also marginally expanded. The ACA requires Medicaid coverage for freestanding birth center services, allows children in hospice to receive concurrently Medicaid payment for services and for medical treatment of terminal illness, and expands financial eligibility payment for family planning services. The ACA also clarifies that Medical assistance includes provision of care and services as well as of payment of the cost of care and services. Some states had argued previously that their Medicaid programs had a responsibility only to pay for services, not to ensure that services were actually available.

The PPACA contains a number of provisions directed toward keeping patients in the community and out of nursing homes, including the Community First Choice Option, the Removing Barriers to Providing Home and Community-based Services program, and the extension of the Money Follows the Person Rebalancing demonstration program. A new section provides that for a five-year period beginning in 2014, the spouses of individuals receiving home and community-based care are subject to the same protections against impoverishment as are the spouses of institutionalized persons.

Some Medicaid provider payments were also cut by the PPACA. Drug companies were required to pay higher rebates and Medicaid disproportionate share hospital payments, which had previously covered hospital’s uncompensated care losses, were also cut given the assumption, which is turning out to be true in some states, that the expansion of insurance coverage would reduce uncompensated care.

The ACA contains a number of provisions and demonstration projects for improving coordination of care for dual-eligibles, individuals eligible for both Medicare and Medicaid, and the quality of care for Medicaid recipients. These include demonstration projects for pediatric accountable care organizations, global payment systems, and integrated care around a hospitalization. They also include a state option for providing health homes to enrollees with chronic conditions and payment adjustments for healthcare acquired conditions. The ACA adds a new program to provide support for pregnant and parenting teens and women, funded at $25 million a year for 10 years.

The Medicaid and Medicare Innovation Center is supposed to spur innovative approaches to delivery and paying for care for Medicaid, as well as Medicare, recipients. Last month, CMS announced the availability of $100 million for a Medicaid innovation accelerator program to identify and improve models for delivery and payment for care, improving data analysis and quality measurement, and improving dissemination of best practices. This is only one of a number of programs encouraging innovation in Medicaid.

Many of these reforms are now in effect, but the most important is not yet fully in place. On the day that the ACA was signed into law, a number of states, eventually 26, filed a lawsuit attacking key provisions in the law. One of these was the Medicaid expansion. The state challengers claimed that the ACA Medicaid amendments crossed a constitutional line. It is clear that Congress cannot force states to participate in a federal program. The Court has long recognized, however, that the federal government can offer funding to the states conditional on their satisfying program requirements. The Court had speculated in earlier cases that a situation could arise in which “the financial inducement offered by Congress” was so coercive that “pressure turns into compulsion.” But no federal court had ever held that a federal law failed this test, and the lower courts rejected the states’ Medicaid claims.

Chief Justice John Roberts, joined by Justices Stephen Breyer and Elena Kagan and supported by a joint dissent from Justices Antonin Scalia, Anthony Kennedy, Clarence Thomas, and Samuel Alito, held that the ACA Medicaid expansion crossed this line. The Court claimed, moreover, that this “coercion” doctrine is fundamental to federalism and that brandishing federal funding to coerce states to participate in federal programs threatens the states’ independent sovereignty.

Because the Medicaid expansion was established as a mandate, not an option, Medicaid law would allow the Department of Health and Human Services (HHS) to threaten to withhold all Medicaid payments from states not adopting it — a penalty that HHS has never imposed. In the Florida case, however, the Court held that such a response was impermissible. Withdrawal of program funding would amount to unconstitutional coercion, given the program’s size and the nature of the expansion.

On average, Medicaid accounts for more than 20% of total state budgets and represents the largest single source of federal funding to the states. Furthermore, said Roberts, the ACA Medicaid expansion changed Medicaid fundamentally. Medicaid, he claimed, “is no longer a program to care for the neediest among us, but rather an element of a comprehensive national plan to provide universal health insurance coverage.” Congress could not constitutionally force the states to implement a new program under the threat of losing existing program funding.

Having found the Medicaid expansion unconstitutional, however, the Court did not strike the expansion, as the dissenters wanted. Instead, it simply prevented HHS from enforcing the expansion as a mandate. The practical effect is to turn it into an option, although the law on the books remains unchanged. At the same time, the Court made clear that Congress has the power to delineate the conditions under which the states can receive new expansion funding.

The Court’s decision left questions regard the scope of its restrictions on federal Medicaid mandates on the states. As I have described, the ACA makes many changes in the Medicaid program. In particular, the law contains a maintenance-of-effort provision barring states from rolling back Medicaid coverage until their health insurance exchanges are operational. The law also requires other changes in coverage and enrollment. The states challenged ACA reforms beyond the expansion of eligibility, including the maintenance-of-effort requirement. But Roberts’s opinion focused only on the expansion group, never mentioning the other reforms; presumably the Court considered them part of the existing program, subject to the program’s normal enforcement tool for mandatory provisions. HHS subsequently made clear that where Medicaid is concerned, the Roberts ruling is confined to newly eligible adults.

In the wake of the Supreme Court’s ruling, 27 states, including the District of Columbia, have decided to move forward with the Medicaid expansion. About 20 are not moving forward at this time, and in 4 or so debate continues. Actually, the debate continues in many of the 20 non-expansion states, but seems unlikely to reach fruition anytime soon.

Although most of the Blue states adopted the Medicaid expansion as written, some of the red states have tried to chart their own path. This is done through the 1115 waiver process. Section 1115 of the Social Security Act allows the Secretary of HHS to waive certain requirements of Social Security Act programs, including Medicaid, to allow research and demonstration projects. These have been quite liberally granted and demonstration projects often continue for years, becoming effectively substitute Medicaid programs. The demonstration projects often seek to increase cost-sharing or impose additional eligibility requirements with the goal of encouraging individual responsibility. Some of these changes are possible, but HHS has been cautious. People are on Medicaid because they have very limited resources. Imposing even a $20 copay can effectively slam the door to services. Deductibles are out of the question.

Surveys show that the country is heading down two radically different paths. In states that have accepted the Medicaid expansion, the program is growing rapidly. In states that expanded Medicaid under the ACA, enrollment, as of May 2014, has increased on average 17 percent, with increased enrollment of 30 percent or more in 10 states. Enrollment in both Nevada and Oregon has increased by about 50 percent. Non-expansion state enrollment has grown by only about 3 percent, with enrollment in Florida, Missouri, Mississippi, and Nebraska actually shrinking. The level of the uninsured is falling rapidly in expansion states, much more slowly in non-expansion states. Four-point-eight million Americans who could have received Medicaid are being denied coverage because they live in non-expansion states.

The ACA not only helps the lowest income Americans; it also helps moderate income Americans. The ACA’s primary strategy for expanding coverage for moderate-income Americans is the premium-assistance tax credit. Beginning this year 2014, Americans earning up to 400% of the poverty level ($45,960 for a single person and $94,200 for a family of four in 2013) who purchase non-group (individual) health insurance through one of the exchanges established under the law are eligible for a tax credit.

The amount of the tax credit is calculated on a monthly basis and is the lesser of (i) the monthly premium cost for the plan that an individual or family is enrolled in, or (ii) the monthly premium for the second lowest cost “silver” plan (a plan in which the insurance pays for 70% of the expected medical costs covered by the plan) that would cover the taxpayer or his or her family minus 1/12 of a specified percentage of the taxpayer’s household income for the taxable year. The percentage increases on a sliding scale from the initial to the final premium percentage within an income tier rising from 2 percent of household income for individuals and households with income up to 133 percent of poverty to 9.5 percent for people with incomes above 300 percent of poverty.

The percentages will increase over time to reflect the growth in health insurance premiums relative to income, so that the share of premiums paid by individuals will remain more or less constant. That is to say, if premiums increase significantly more rapidly than income, as they have in the past, the percentage of income that individuals will have to spend on premiums will increase so that the individual and the government will continue to pay roughly the same proportion of the premium.
The premium tax credit is adjusted for age, as are premiums. The cost of any benefits covered by an insurance policy, beyond the essential benefits, are not considered in setting the adjusted monthly premium for premium tax credit calculation purposes. But, states must cover the cost of any benefits that they require qualified health plans to provide to individuals in addition to the essential health benefits, whether or not the insurance is subsidized by a tax credit or provided through an exchange.

Persons who are eligible for Medicaid are not eligible for the premium tax credits. Neither are people who are incarcerated or who are undocumented aliens. Aliens legally present in the United States who are not eligible for Medicaid (generally, those present in the country for fewer than 5 years) but who have incomes below 100 percent of the poverty level are also eligible. But United States citizens with incomes below 100 percent of the poverty level in states that reject the Medicaid expansion are not eligible for premium tax credits.

Most persons who have employer coverage are not eligible for premium tax credits. However, employees may be eligible to purchase individual coverage through the exchange with assistance from a premium tax credit if they are eligible for an employer-sponsored plan but their required contribution for the plan exceeds 9.5 percent of household income (indexed for inflation). Under current regulations, this calculation would be based on the cost of self-only coverage, so that a family may be refused a premium tax credit if coverage of the individual employee is affordable even though the premium for family coverage exceeds 9.5 percent. An employee may also be eligible if the employment-related “plan’s share of the total allowed costs of benefits provided under the plan is less than 60 percent of such costs.” These provisions only apply if the employee or family is in fact not covered by the employment-related plan.

Individuals and families who qualify for premium tax credits get fairly comprehensive coverage. Qualified health plans sold through the exchanges must cover the essential health benefits, which covers most commonly used medical services except for adult dental and vision care. Cost sharing is high, however, with deductibles in the lowest cost bronze plans often exceeding $5000 and in the benchmark silver plans $2500 or above.

The reform legislation provides not only for tax credits to reduce the cost of health insurance premiums, but also for direct payments to qualified health plans to reduce the cost-sharing (including deductibles, coinsurance, and copayments) of eligible individuals beginning this year. Cost sharing is limited for plans available through the exchange in two different ways. First, the legislation imposes a maximum out-of-pocket expenditure limit, basically equal to the limit imposed on high-deductible policies that accompany health savings accounts ($6,350 for an individual and $12,700 for a family in 2014). Second, qualified health plans in the individual and small-group market must offer coverage of a specific actuarial value fitting into one of four “precious metal” tiers (bronze, silver, gold, and platinum), ranging from 60% to 90% actuarial value. Although “actuarial value” is determined by the overall structure of a plan and does not dictate the out-of-pocket expenses a particular individual or family will incur in a particular year, higher actuarial value plans offer lower cost-sharing and more affordable health care, but charge higher premiums.

“Cost-sharing reduction payments” are payments made by the federal government directly to an insurer on behalf of an “eligible individual” to lower that individual’s cost-sharing obligations. An eligible individual is a person who enrolls in a silver tier plan in the individual market through the exchange and whose household income is above 100 percent and does not exceed 400 percent of the poverty level. These payments are not available to persons with employment-based coverage.

Cost-sharing reduction payments reduce the statutory out-of-pocket limit for persons with household income not exceeding 250 percent of the poverty level. These reductions in the out-of-pocket limit cannot increase the actuarial value of the plan above the levels specified in the statute. In addition, however, to the reduction of the out-of-pocket payments, cost-sharing subsidies must also increase the actuarial value of plans for lower-income enrollees. Cost-sharing reduction subsidies must assure that persons with incomes above 100% and not exceeding 150% of the poverty level have coverage with an actuarial value of at least 94%; persons with household incomes of above 150% and not exceeding 200% of the poverty level have coverage with at least 87% actuarial value; and persons with household income above 200% and not exceeding 250% of the poverty level have coverage with at least 73% actuarial value. Native Americans with household incomes not exceeding 300% of the poverty level are not responsible for cost-sharing. Cost-sharing reductions apply only for essential benefits.

Enrollment in qualified health plans with premium tax credits got off to a very slow start with the federal exchange, which covers 36 states, and state exchanges in many of the remaining states, failing at the outset. By the end of the 2014 open enrollment period, however, over 8 million Americans had chosen a health plan through the exchanges, and probably 7 million of those paid their first premium and therefore actually qualified for coverage.

Recent reports concur that the number of uninsured has been reduced dramatically. A recent Gallup Poll shows that the percentage of the population that is uninsured is the lowest since they started polling, at 13.4 percent, down from 18 percent in 2013. A recent Urban Institute Poll shows that the percentage of uninsured has dropped to 10.1% in states expanding Medicaid, although it is still at 18.3 percent in states that have not. A recent Commonwealth Fund report finds that 9.5 million fewer people are uninsured, including 5.7 million young people.
Many of these 87 percent of the 5.4 million Americans who chose a health plan through the federal health exchange qualified for some financial help. The average monthly tax credit this year is $264. Without the federal help, the average premium chosen by people eligible for a tax credit would have been $346 per month, and the subsidy lowered the consumers’ premiums, on average, by 76 percent. The result is that four out of five people with subsidies are paying premiums of no more than $100 a month.
Many of these people may still be unable to afford care because of high deductibles. But we don’t know yet the extent to which cost-sharing reduction payments reduce these. Surely for many of the newly insured, cost-sharing reductions have been substantial. Medicaid, of course, generally has minimal cost sharing.
The ACA also contains numerous other provisions that benefit lower-income Americans. It establishes creates a Prevention and Public Health Fund to provide for expanded national investment in prevention and public health. It establishes a new program of school-based health centers. It provides for competitive grants to states and communities for the implementation, evaluation, and dissemination of evidence-based community health activities and for healthy-aging, living well programs. It also creates programs to expand access to immunization for adults. It expands the collection of data on health disparities. It creates special programs for pain-care management, childhood obesity, diabetes, depression, congenital heart disease, workplace wellness programs, and breast cancer in young women.

The bill also increases by $10 billion new appropriations for community health centers. These centers will also serve the new Medicaid recipients (as well as the immigrants excluded from the exchanges). In addition, the ACA provides several billion more dollars for the National Health Service Corps.

On balance, The ACA will improve and is improving the lives of lower income Americans. A Brookings study found that it would raise the real incomes of the bottom 10th of the population by 7%, of the bottom fifth by 6%. In states where Medicaid has expanded, the lowest-income Americans have access to health coverage and health care. In all states, Americans with incomes above 133 % of the poverty line have better access to health insurance and in many instances to health care. The ACA also increases financial security for lower and moderate income Americans.

But it is not an improvement for all. The ACA requires large employers to cover their full-time employees or pay a penalty. Full-time is defined as 30 hours or more on average. Some employers are cutting hours of part-time workers to avoid offering coverage. Due to what is referred to as the family glitch, if employees are offered affordable coverage, that is employee-only coverage that costs less than 9.5 percent of their income, they and their families are not eligible for premium tax credits. Many low-income individuals continue to find coverage unaffordable, even with tax credits, and the health care unaffordable with high deductible plans.

Moreover, it will take more than health reform to effectively address poverty in the United States, or even to address health disparities. Differences in mortality and morbidity between low and high income Americans are striking. Yet much of this difference is due to factors other than medical care: housing, diet, education, environmental risk, occupational risk, even stress. Health care is a substantial factor, but even in countries that have long had universal public health insurance, disparities remain. The ACA, in the end, is not a cure for poverty, but it is certainly a move in the right direction.

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