By Hannah Karpman, Phd., Joshua L. Miller, Phd., and Crystal M. Hayes, MSW
Republicans across the ticket built their campaigns primarily on one promise: unraveling an Obama legacy. Now that they have control of both the White House and both branches of the legislature, they will face increasing pressure to make good on these promises. While we’ve thus far seen mostly executive orders, which are easy to sign and look good for the camera, the messy work of legislation will eventually begin, and Republicans know they must deliver to their electorate. A key piece of this undoing will be the repeal of the Affordable Care Act, also known as Obamacare.
While all of the administration’s policy initiatives will impact social work and our clients, this one has the potential to substantially alter the landscape of our profession. Social workers need to be hyper-vigilant about the process of repealing (and maybe replacing-we’re not hopeful) Obamacare. In this piece we will discuss lessons we can learn from how Obamacare was constructed and presented, what the Affordable Care Act does, the key issues to watch, the possible impacts on social work practice, and how to engage in this fight.
The proper name for Obamacare is the Affordable Care Act (ACA). Its nickname is wildly inaccurate. The original piece of legislation was written not by Democrats, but by the conservative political think tank the Heritage Foundation in 1993. The foundation of the ACA is actually a Republican idea, taken up by the Massachusetts legislature, which was trying to build a health reform package for then-governor Republican Mitt Romney.
The Massachusetts version of what became the skeleton of the Affordable Care Act was signed by Romney in an elaborate televised ceremony. It was widely expected this achievement would be touted as the foundation of Romney’s run for the presidency. The scene was made for a presidential campaign ad: Romney, looking presidential, signing a landmark piece of legislation in front of two signs that proclaimed “Making History in Healthcare.” And make history they did ― because that bill became the platform on which federal health reform was built. A critical mistake by Democrats was that they let the Republicans disown it.
The Affordable Care Act is predicated on the assumption that the best way to provide access to health care is to do so through the private market ― that is, through health insurance companies. In fact, one could argue that the ACA doesn’t insure access to health care, it insures access to insurance. It does so primarily through two mechanisms. The first mechanism is that the Affordable Care Act provides subsidies to individuals (dependent on income, but the eligibility requirement include many middle class families) in order to help them buy private insurance in government sponsored marketplaces. As of March 2016, close to 9.5 million people bought insurance using such subsidies. Without them, many would likely be unable to afford insurance.
The second mechanism is a substantial expansion of Medicaid. The expansion made many people who were previously ineligible for Medicaid able to access a state based public insurance program, often with no premium or co pays. The expansion specifically targeted children and adults who were low income by creating a federal income eligibility guideline at 138 percent of the poverty line. Previously some states only covered the very poor (for instance, only those below 50 percent of the poverty line.
The combination of these two provisions dramatically altered the landscape of funding for mental health and substance abuse services. Community mental health centers and other providers who previously relied on external or government funding to serve uninsured communities were, overnight, providing services to individuals with insurance. They became insurance driven businesses. As a result states reduced or eliminated other sources of revenue for such providers, because they became unnecessary.
While ACA expanded access to private insurance, it also created a floor for insurance benefits by establishing essential health benefits. One key benefit has been largely ignored by recent press on the ACA: parity in coverage for mental health and substance abuse conditions for individuals who purchased individual health insurance coverage. Parity requirement mandate that health insurers provide the same level of benefits for physical health conditions as they do for mental health or substance abuse conditions.
Before parity, many insurers covered physical health care, but required high deductibles or out-of-pocket payments for mental health or substance abuse treatment. While the Paul Wellstone and Pete Domenici mental Health Parity and Addiction Equity Act of 2008 created parity for those who were enrolled in large group plans (e.g. large employer plans), it was expanded by ACA to include individuals who purchase insurance outside of their employee group and to those who are in small group plans and extended the definition of parity for existing plans (for instance out of network benefits for both physical and mental health must be equal).
A second and easily targeted floor benefit is the provision of any birth control mechanism prescribed by a doctor, without a co-pay or application of deductible. As a faculty teaching undergraduate students when ACA was implemented, this was a benefit I heard a lot about.
The Affordable Care Act isn’t perfect. In fact, many liberals have criticized it as a giveaway to private insurance companies, who profited heavily from its privatized structure. It does little, or nothing to control costs. It’s only cost control mechanism is the individual mandate, which forces everyone to purchase insurance. In doing so, the mandate spreads the cost of health care across the healthy and the sick, reducing the average cost to the individual. Republicans, stubbornly and without reason, have targeted this particular piece of the legislation which is why they have been slow out of the starting blocks to repeal and replace. Without this provision, the cost of insurance access will skyrocket. It’s much easier to critique something when you don’t have to understand or fix it. On the other hand, this lack of good replacement offers a potential opportunity to advocate for something even better than the Affordable Care Act, perhaps something more akin to universal coverage. Such an offering could still rely heavily on a the private market, for instance, a structure like that the one in Israel.
So what does this all mean for social work, and for our clients? To echo a favorite saying of my grandmother, it depends. However, there are key areas we need to watch closely, which we’ve highlighted above and are worth reiterating.
- What happens to mental health and substance abuse parity? If this provision is eliminated, the funding mechanism on which many of our agencies, and therefore our employment relies will disappear. In the past eight years, funding for mental health care has shifted from being the responsibility of state and federal government to the responsibility of health insurers. If given the opportunity to cut these benefits, insurers might, and there is no more state or federal safety net to catch us.
- What happens to Medicaid? Many community mental health primarily serve Medicaid recipients, and therefore rely on Medicaid billing to stay afloat. Even if parity stays, if Medicaid expansion shrinks, community mental health centers will go back to providing services to those who are uninsured, without the support of other funding mechanisms that existed before the ACA?
- What is the “replacement” option, if there is one? Republicans have long supported health savings accounts, which essentially allow individuals to direct their income, tax free, into accounts they can use to purchase health care. This is an oft-used Republican strategy when they are trying to do away with a social benefit program. The problem here is an obvious one. If you don’t have income, or you need all of your income to do things like pay rent, this option does you little good. But they won’t mention that part.
- Do nationalist, white supremacist views begin to invade the health insurance debate limiting access to benefits to certain groups of people deemed “unworthy”. Think eligibility guidelines that exclude those who were previously incarcerated. Think reduced access for women’s reproductive health care. Think reduction of benefits for those who identify as transgender or gender non conforming.
- How many people will lose their coverage or have the quality of their coverage severely reduced and who is the most likely to be impacted?
Social workers, and our lobby have been remarkably quiet thus far. We cannot afford (quite literally our salaries depend on it) to sit this one out. Below we outline some strategies for resistance.
Stop using the term “Obamacare.” Use “The Affordable Care Act” and be specific about its benefits when you talk about it. Polling data shows that while people don’t support “Obamacare,” when they are asked about the specific provisions of the bill, or about the Affordable Care Act, their opinion magically changes. Calling the ACA “Obamacare” was a successful attempt to racialize the Affordable Care Act, which reduced white support. Make sure your clients and co-workers (many social workers who work fee for service access health insurance through exchange subsidies) understand how and what they receive through the Affordable Care Act, and how its repeal may affect them. If Trump and the Republicans gut the ACA, make sure to refer to its replacement at Republican-care. Make them own it.
Help Individuals Be Prepared
Reproductive advocacy groups have advised women who use birth control to consider getting an IUD, in the event that birth control coverage is eliminated. While we don’t advocate providing specific advice about medical treatment, it may be helpful to help clients think through what medications and treatments they currently rely on their health insurance to cover, and how they may choose differently if the possibility of losing their health insurance was looming. Some individuals who are taking a wait and see approach before having that recommended surgery might choose differently. In a similar vein, know where individuals can turn to for medication assistance, financial assistance for mental health or health care, or other kinds of financial assistance to offset the cost of health care in the event they lose their insurance and need to access those services.
Get Your Agency Ready
If your agency or employer relies heavily on insurance to keep the lights on, now is the moment for another business plan. We can only continue to provide services to the clients who rely on us if we are innovative and entrepreneurial in our approach. Gather senior leadership. Where else can you find revenue? What grants can you write that you haven’t prioritized? What corporations who may previously have been unwilling to engage might now consider supporting mental health (see the list of corporations dropping the Trump clothing line). Can you reach out to potential donors with a “if this happens doomsday scenario” and get commitments in advance?
Be Willing to Find Allies in Unlikely Places
Social workers love to complain about managed care companies and health insurers and pharmaceutical companies. That will do us no good here. They are our ally in this fight and have much to lose in the way of business and revenue should the Republicans move on these promises. We need to partner with their powerful lobbying groups and get a seat at that table. Similarly, if you have a friend on the other end of the political spectrum, now is the time to talk to them about ACA in personal terms. Emphasize how a repeal will impact their lives. Alicia Garza of Black Lives Matters says “our cynicism will not build a movement. Collaboration will.” She’s right.
As the Republicans try to dismantle the ACA, it will be important to show up in large numbers in the offices of Representatives and Senators. Come with stories as well as data about the negative impact of repeal. Demand that they offer a credible alternative.
The Republicans and Trump realize that aspects of the ACA are very popular when people understand them. Social workers are well positioned to educate the public about ACA. Write op/eds, publish an article in a local paper, post flyers about it in a swing community nearby, hold an ACA teach in. Send an ACA update in an agency newsletter. Get the word out. The key message here. Do you want to lose your insurance? Do you want to pay more for your health care?