Protecting and shoring up the Affordable Care Act is expected to be of key importance under the new Biden administration, reversing years of attacks against the law.

During his term in office, President Donald Trump worked to undermine the ACA, shortening health insurance enrollment periods and refusing to defend the law in court, among other actions. From 2017 through 2019, 2.3 million people lost health insurance coverage, and millions more lost it during the pandemic.

The Biden administration is expected to reverse many of Trump’s ACA changes, working in tandem with Congress where needed. But not all improvements to the law require congressional approval.

In lieu of legislation to support Medicaid expansion, Biden could explore implementing partial expansion in holdout states, said Sara Rosenbaum, JD, professor of health, law and policy at the Milken Institute School of Public Health at George Washington University.

Currently in states that have expanded Medicaid eligibility under the ACA, people who earn up to 138% of the federal poverty level qualify for the program. Biden could test and evaluate raising eligibility to 100% of the poverty level, which would bring insurance to more low-income people, she said. The compromise might be enough to entice holdout states to support expansion.

According to the Center on Budget and Policy Priorities, Medicaid expansion has allowed 12 million people to gain health insurance coverage since the program began. And at least 4 million more people would become eligible if the 12 remaining states expanded their programs.

Biden could also use Section 1115 of the Social Security Act to broaden Medicaid options for holdout states. Section 1115 permits the federal government to implement pilot programs that waive typical uses of Medicaid state funds, with the goal of improving care, increasing efficiency and reducing costs.

In January 2020, the Centers for Medicare and Medicaid Services announced that states could use the Section 1115 waiver to respond to health needs of people with COVID-19 during the national health emergency.

States could use the section waiver to pilot partial Medicaid expansion, Rosenbaum said. The program could remain after the pandemic ends, given that Americans will still be at risk of COVID-19 and suffering economically.

"I consider the greatest health inequity problem this country has is the 12 remaining states where millions of people — disproportionately African American — simply have no way to get coverage,” Rosenbaum said. “We have to take care of this problem. It is a national tragedy and an international embarrassment.”

Other changes the Biden administration may make to shore up the ACA include reinstating funding for health insurance enrollment marketing and cost-share subsidies to insurance companies that help keep them in ACA health exchanges.

But reversing other Trump administration measures may not be as easy. In 2018, CMS began allowing states to impose work requirements on people who receive Medicaid benefits. When Arkansas implemented work requirements in June 2018, more than 18,000 people were disenrolled in the first six months. <p:>The requirements were struck down in court, and this spring, the U.S. Supreme Court will hear cases on appeal from Arkansas and New Hampshire. Justices are expected to weigh in on the broad topic of the federal government’s use of Section 1115, Rosenbaum said.

"The case will deal with the scope of federal demonstration powers,” she said.

The Supreme Court will also rule on a case this year involving the ACA and the individual mandate, which required that people who did not have health insurance pay a tax penalty. As 2017 legislation eliminated the penalty, ACA opponents argue that the entire law is unconstitutional.

APHA, public health schools and other partners supported the ACA in a friend-of-the-court brief on the Supreme Court case.

“Eliminating the ACA would end programs, terminate funds, eliminate insurance protections, and — on the whole — destroy many of the gains that the country has made since 2010,” the year the ACA became law, the brief said. “The damage to public health would be incalculable.”

For more information on the public health priorities of the Biden administration, read the February/March issue of The Nation’s Health on Feb 4.

Photo by FatCamera, courtesy iStockphoto: The Affordable Care Act has helped bring a measure health equity to the U.S., despite years of attacks on the law. President Joe Biden is expected to reverse many ACA changes imposed by the Trump administration to weaken the ACA. But other changes to protect and expand the law will not be as easy.