Repealing ACA: Pushing thousands of Iowans to the brink
Likely turmoil in insurance market, higher premiums, and harm to the economy
Instead of incentives to invest, the proposals reward decisions made with no subsidy needed
Updated March 2017
By Peter S. Fisher
Repealing the Affordable Care Act (ACA) without an adequate replacement, as Congress and the incoming Trump administration appear poised to do, jeopardizes the health care coverage and economic well-being of the most vulnerable Iowans. About 230,000 fewer Iowans would have health coverage in 2019 if the law is repealed, including 25,000 children. Thousands of adults working in low-wage jobs — such as those waiting tables, working on construction sites, bagging groceries, or providing care to children, the sick, and the elderly — would lose coverage if the Medicaid expansion is repealed. For families unable to afford health coverage on the individual market prior to health reform, coverage subsidized by tax credits could disappear, and 42,000 individuals would lose their insurance. More people would turn to hospitals and other health providers for uncompensated care, which would likely be provided in emergency rooms, leaving those who are insured to pay the bill through their own premiums, or for health-care providers to swallow the cost. Iowa’s economy would suffer as $626 million in federal funds would be withdrawn from the state, costing Iowa 6,700 jobs. The insurance market would be thrown into immediate disarray, raising premiums and reducing insurance options. Such are the prospects for Iowa as decisions loom in Washington on the ACA.
The Affordable Care Act dramatically expanded health insurance coverage in Iowa
The number of Iowans without health insurance declined by almost 93,000 between 2013 (prior to implementation of the Affordable Care Act) and 2015, the second year in which the ACA and the insurance exchange were fully implemented in Iowa. This represents a 37 percent decline in the number of uninsured. Statewide, the percent of persons without insurance declined from 8.1 percent to 5 percent. Increased coverage came in two ways: (1) about 47,000 more individuals purchased private insurance directly, with subsidies available to most of those through the ACA, and (2) about 70,000 more Iowans obtained health insurance from Medicaid.
At the same time that options expanded for people to access publicly funded or subsidized coverage, the number of Iowans obtaining health insurance through their employer actually increased by 28,000 over the two-year period. The ACA, in other words, does not appear to have caused employers to eliminate health insurance and push employees onto public plans.
The most dramatic decrease in the number of uninsured occurred for non-Hispanic white Iowans, among whom the number dropped by 85,000, accounting for 92 percent of the decrease statewide. The uninsured rate for this population declined from 7 percent to about 4 percent. The ACA had much less dramatic effect in reducing the uninsurance rates among Hispanics, African Americans and other non-white Iowans, where the uninsured share remained at 12 percent or higher.
The percent of the population that was uninsured dropped in nine of the 10 most populous counties in Iowa, in most cases by a substantial amount. The uninsured rate in the more rural remainder of the state also declined dramatically, from 9.2 percent to 5.3 percent. All told, about 41,000 fewer Iowans in the 10 largest counties were uninsured in 2015, while 52,000 fewer Iowans in the remainder of the state had coverage.
Repeal would increase the number of uninsured Iowans
The ACA has made good-quality health insurance available to thousands of low-income individuals and families in Iowa who otherwise could not afford coverage. About 55,000 Iowans purchased insurance on the exchange during the 2016 enrollment period, and 85 percent of them qualified for the premium tax credit. The average monthly premium for those purchasing insurance on the exchange was $425, with $303, or 71 percent of this cost, covered by the credit. The ACA subsidy that is now in danger reduced the average cost to ACA enrollees to $122 per month. Nearly 28,000 people in this group also received cost-sharing reductions (CSRs), which lowered deductibles and other out-of-pocket costs for them by roughly $28 million that year.
The Urban Institute has estimated that if the ACA is repealed, 230,000 fewer Iowans will have health insurance coverage in 2019 than if the law is left as is. Of these, 42,000 are individuals who will receive tax credits for the purchase of health insurance if the ACA continues, credits worth on average $4,281 per recipient per year. The credit covers over two-thirds of the cost of health insurance on average. Few people could afford to keep their coverage if they lose that subsidy.
As a result of these losses in coverage, the Urban Institute projects that ACA repeal would increase the number of uninsured in Iowa from 153,000 to 383,000, a 150 percent increase. This includes an increase of 25,000 in the number of uninsured children, as well as 68,000 more uninsured parents. The percentage of Iowa children without health insurance would more than double, from 3 percent to 6.2 percent.
Taking Medicaid coverage away from thousands of adults would likely lead to an increase in the number of uninsured children. This is because adults who are uninsured are less likely to enroll their children in Medicaid or hawk-I. For many children in Iowa, this will mean not just poorer health, but poorer long-term prospects overall. Research has shown that better health care as a child is associated with greater educational attainment and higher earnings as an adult.
Repeal of the Medicaid expansion would cut eligibility below pre-ACA levels
In 2014 Iowa created its own version of the Medicaid expansion, called the Iowa Health and Wellness Plan. As of January 2017, 151,000 people were enrolled in the Wellness Plan. See Appendix Table for enrollment by county. All of those individuals now in the Wellness Plan are at risk of losing health insurance if the Medicaid expansion portion of the ACA is repealed.
Prior to the ACA, Iowa had created a Medicaid waiver program called IowaCare that extended Medicaid benefits to many adults not eligible under traditional Medicaid. There were 69,000 people enrolled in IowaCare in FY2013. With the advent of the ACA in 2014, those enrolled in IowaCare were automatically shifted to the Iowa Wellness Program, and IowaCare ceased to exist. If Congress repeals the Medicaid expansion, all those in the Wellness Program would be at risk of losing coverage. People losing coverage would include those formerly in IowaCare, unless the state re-created such a program under a waiver request once again and got approval for that waiver from the federal government. This is unlikely. Thus the repeal of the ACA could leave tens of thousands of adults uninsured who actually were insured prior to the ACA, or who could have been covered if IowaCare still existed. This would leave low-income Iowans worse off than they were in 2013, prior to health reform taking effect.
Working Iowans would be hurt by Medicaid expansion repeal
The majority of the non-elderly adults receiving Medicaid are working Iowans. In 2015, 61 percent of Medicaid recipients age 18 to 64 were working at least part time. A third of those were working full time at low-wage jobs that left them earning near the poverty line. Many of these adults get their health coverage through the Iowa Wellness Program and are thus at risk of becoming uninsured if the Medicaid expansion is repealed.
Among the adult Medicaid recipients in Iowa who are working, about 45 percent work in 10 industries. They are waiting tables, working on construction, bagging groceries, or serving children, the sick, and the elderly. They are working in jobs that pay little and provide few if any benefits.
Uncompensated care would rise with repeal
The ACA expanded insurance coverage to thousands of Iowans who would otherwise have sought emergency room or other care that they could not pay for, but which hospitals and doctors nonetheless are obligated to provide. This “uncompensated care” was greatly reduced by the ACA. With repeal and the loss of insurance coverage for 230,000 Iowans, it is estimated that total uncompensated care in Iowa in 2019 (assumed to be the first year in which repeal is fully in effect) would more than triple, from $345 million to $1.2 billion. Over a 10-year period, a $10 billion rise in uncompensated care in Iowa is anticipated. All Iowans would feel the effects, as hospital fees and insurance rates would rise to make up for these costs, and as hospitals retrench.
The decline in health insurance coverage and the rise in uncompensated care could be especially challenging for Iowa’s rural hospitals. Rural hospitals are more likely to be in a precarious financial situation if they are in a state that did not expand Medicaid, and repeal would throw all Iowa hospitals into that situation. Since 2010, 80 rural hospitals across the country have closed, the majority in non-expansion states.
Repealing the ACA would cause immediate harm
Repeal of the ACA would likely follow the provisions of the repeal bill passed by Congress last year. This would eliminate immediately the individual mandate to purchase insurance or pay a penalty, while retaining popular provisions such as the requirement that insurance companies not deny coverage because of pre-existing conditions. The result is that many healthy individuals would drop their coverage. Insurance companies would be left with the sickest and most expensive customers, which would prompt some to leave the state’s individual insurance market or to raise rates for remaining customers if they stayed. The health insurance market would thus be devastated quickly, even though full repeal of the subsidies and other provisions of ACA would be delayed, possibly until 2019.
Repeal would also endanger some of the ACA’s most important consumer protections. No “replacement” plan has been proposed, but it is likely that the quality of insurance policies in the individual market would deteriorate, with rising deductibles, the return of limits on how much insurers will pay out in benefits each year or over a person’s lifetime, and failure to cover such things as maternity care, mental health, or prescription drugs.
With repeal of the individual mandate and the subsidies, it would be untenable to maintain the ACA’s protections for people with pre-existing health conditions. In Iowa, the number of adults with pre-existing conditions that would have led to denial of insurance coverage prior to the ACA has been conservatively estimated at 448,000, or about 24 percent of non-elderly adults in the state. Ensuring the individual insurance market is accessible and affordable for this group, should they need to purchase coverage there, has been a major achievement of the ACA , but one made possible only because of the mandate and the marketplace subsidies, which broadened the pool of individuals the insurance companies were covering to include many healthier adults. Without the broader pool, insurance companies will not continue to offer quality, affordable policies, to the detriment of all those buying health insurance in Iowa.
Contrary to what some in Congress have been saying, the exchanges are not in a death spiral — higher premiums causing healthy individuals to forgo insurance, leaving the insurance companies with a more costly pool, leading to higher premiums, etc. Enrollment through the exchanges has increased each year since inception in 2014, and 2017 enrollment is ahead of last year’s. There is evidence that the premium increases this year are a one-time correction for underpricing in previous years, not the beginning of a trend. In fact it is repeal, not continuation, of the ACA that would push the exchanges into a death spiral.
Repeal would shower benefits on the wealthy
Repeal of the taxes financing the ACA would lavish tax cuts on the highest-income households in the country. The Medicare taxes imposed by the ACA fall only on individuals with incomes above $200,000 or couples with incomes above $250,000. The 400 richest households in the country would receive a $2.8 billion windfall in 2017 if these taxes were ended, for an average tax cut of about $7 million a year for each household. Without the revenue from these and other taxes imposed by the ACA, it would be difficult or impossible to finance a replacement.
Repeal would harm Iowa’s economy
The repeal of the ACA would have a substantial impact on the Iowa economy, cutting off billions in federal money flowing into the state, and reducing income and employment, not just in the health care industry, but throughout the economy.
Repeal of the ACA would result in the loss of $626 million in federal funds in 2019, and a total of $7.4 billion from 2019-2028. That would reduce payments to health care providers throughout the state, who in turn would reduce purchases from vendors and cut employment. Ripple effects would follow: vendors would cut payroll, and the reduced spending by employees both of the health care providers and of the vendors would mean reduced purchases of goods and services in Iowa, and reduced state taxes. Repeal of the ACA (including the taxes that finance it) would cost Iowa 6,700 jobs, not just in the health care sector, but also in sectors such as construction, retail, finance and services.
 U.S. Department of Health and Human Services, ASPE Issue Brief, March 11, 2016. Health Insurance Marketplaces 2016 Open Enrollment Period: Final Enrollment Report For the period: November 1, 2015 – February 1, 2016.
 Linda J. Blumberg, Matthew Buettgens, and John Holahan. Implications of Partial Repeal of the ACA through Reconciliation. Washington, DC: The Urban Institute, December 2016. Available online at http://www.urban.org/research/publication/implications-partial-repeal-aca-through-reconciliation
 Linda J. Blumberg, Matthew Buettgens, and John Holahan. Implications of Partial Repeal of the ACA through Reconciliation. Washington, DC: The Urban Institute, December 2016. Available at http://www.urban.org/research/publication/implications-partial-repeal-aca-through-reconciliation
 Matthew Buettgens, Genevieve Kenney, and Clare Pan. Partial Repeal of the ACA through Reconciliation: Coverage Implications for Parents and Children. Washington, DC: The Urban Institute, December 21, 2016. Available at: http://www.urban.org/research/publication/partial-repeal-aca-through-reconciliation-coverage-implications-parents-and-children.
 Government Accountability Office. Medicaid and CHIP: Given the Association between Parent and Child Insurance Status, New Expansion May Benefit Families. February 2011. Available at: http://www.gao.gov/new.items/d11264.pdf .Georgetown Center for Children and Families, Medicaid Expansion: Good for Parents and Children. January 2014. Available at: http://ccf.georgetown.edu/wp-content/uploads/2013/12/Expanding-Coverage-for-Parents-Helps-Children-2013.pdf
 Medicaid’s Long-Term Earnings and Health Benefits. Center on Budget and Policy Priorities, May 12, 2015. Available at: http://www.cbpp.org/blog/medicaids-long-term-earnings-and-health-benefits Medicaid at 50: Covering Children Has Long-term Educational Benefits. Center on Budget and Policy Priorities, July 7, 2015. Available at: http://www.cbpp.org/blog/medicaid-at-50-covering-children-has-long-term-educational-benefits
 Traditional Medicaid covers low-income individuals who are aged, blind, disabled, pregnant women, children, or parents of children on Medicaid.
 Matthew Buettgens, Linda J. Blumberg, and John Holahan. The Impact on Health Care Providers of Partial ACA
Repeal through Reconciliation. The Robert Wood Johnson Foundation and the Urban Institute, January 2017.
 Gary Claxton, Cynthia Cox, Anthony Damico, Larry Levitt, and Karen Pollitz.Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA. Kaiser Family Foundation, December 12, 2016. Available at: http://kff.org/health-reform/issue-brief/pre-existing-conditions-and-medical-underwriting-in-the-individual-insurance-market-prior-to-the-aca/
 Sarah Lueck. “Commentary: Even as Insurance Market Improves, GOP’s ACA Repeal Would Kill It.” Center on Budget and Policy Priorities, January 17, 2017. Available at: http://www.cbpp.org/health/commentary-even-as-insurance-market-improves-gops-aca-repeal-would-kill-it
 Brandon DeBot, Chye-Ching Huang, and Chuck Marr ACA Repeal Would Lavish Medicare Tax Cuts on 400 Highest-Income Households. Center on Budget and Policy Priorities, January 12, 2017 Available at: http://www.cbpp.org/research/federal-tax/aca-repeal-would-lavish-medicare-tax-cuts-on-400-highest-income-households
 Includes Medicaid expansion funding and insurance subsidies. Linda J. Blumberg, Matthew Buettgens, and John Holahan. Implications of Partial Repeal of the ACA through Reconciliation. Washington, DC: The Urban Institute, December 2016. Available online at http://www.urban.org/research/publication/implications-partial-repeal-aca-through-reconciliation
 Josh Bivens. Repealing the Affordable Care Act Would Cost Jobs in Every State. Economic Policy Institute, January 31, 2017. http://www.epi.org/publication/repealing-the-affordable-care-act-would-cost-jobs-in-every-state/
Peter S. Fisher is Research Director for the Iowa Policy Project. He holds a Ph.D. in economics from the University of Wisconsin-Madison and is professor emeritus of Urban and Regional Planning at the University of Iowa. A national expert on public finance, Fisher is frequently quoted in the Iowa and national media on issues involving tax policy and economic development strategies. His critiques of various state business climate rankings are posted on a website, Grading the States, at www.gradingstates.org.
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