America’s Most Vulnerable Still at Risk Under ACA

The ‘groundbreaking’ healthcare law ignores millions who need it most

Published on October 4, 2012 by Larkin Callaghan

At 26 years old, I found myself in a predicament—my job didn’t offer health benefits, I definitely couldn’t afford a private plan, and I didn’t qualify for Medicaid. I was uninsured.

This is hardly breaking news. But as a public health professional, I had always been certain that I would never be one of those without healthcare coverage—at risk for potential financial and emotional disaster were illness to strike.

Knowing I didn’t have insurance, my mind turned every stomach pain I had into appendicitis. Every headache morphed into a potential brain tumor. Every time I tripped on the sidewalk, I said a brief prayer that I hadn’t twisted my ankle beyond self-healing repair. But I was fortunate: I’m a fit young woman. I was able to buy healthy food and exercise regularly, I had no chronic health issues, and I obsessively look both ways before crossing any street. With these due precautions, and with a little luck, that uninsured phase of my life passed without any real incident (other than a little anxiety and hypochondria).

Others haven’t been so lucky. Here’s a snapshot of some of the more disturbing statistics about the health of Americans: One in three Americans are obese, and over 25 million Americans have diabetes. It’s no wonder then that 27 million Americans have heart disease. And it doesn’t stop with physical health: over 25 percent of Americans have a diagnosable mental illness.

It’s clear healthcare coverage is important in America, and 50 million of us don’t have it.

In that regard, the passing of the Affordable Care Act (ACA) was a relief for many who needed affordable insurance. Young adults are now covered on their parents’ plans until they’re 26. Medicaid was expanded to cover many more Americans than it used to cover. Perhaps most importantly, insurance companies can no longer exclude people for having pre-existing conditions that precluded them from getting the coverage they needed previously.

While all this is wonderful, it’s clear that the law falls short in some really important ways. A startling 30 million Americans will remain uninsured—still unable to get the coverage they need.

First, there are the unemployed who will miss out on the main mechanism through which many Americans will get coverage—their jobs. There are also the workers at companies with less than 50 employees who are in trouble because their employers are neither required to provide coverage nor penalized for not doing so. Private insurance is expensive, and beyond feasible for many of these uncovered Americans who will need it. And several states are balking at the ACA-offered Medicaid expansion package for political reasons, leaving more than just a few Americans without coverage.

Luckily, for those whose incomes put them at 133 to 400 percent above the poverty line (about $11,000 in annual income for an individual and $22,000 for a family of four), there will be some help from the federal government with state health exchanges, which offer subsidies to buy insurance from a range of plans in their states.

But those earning less than 133 percent of the poverty line are in a pickle. Not only won’t they qualify for these exchanges, but they’ll make too much to qualify for Medicaid—with annual income caps in some states, like Texas, as low as $5,000 a year.

The implications extend beyond adults to children in low-income households, as well. A family health insurance plan that covers children costs $4,530 a year on average, even with employer-sponsored coverage. So those folks without employer-sponsored insurance have to pay even more to insure their children—a very real struggle for low-income families. This predicament leaves many kids without any healthcare net. What’s worse,  Children’s Health Insurance Program (CHIP), a state-run program offering coverage for children in families that make too much for Medicaid but who cannot afford private plans, is facing major funding cuts, forcing more children to rely on that family coverage from their already struggling parents.

The ACA was certainly a big win for healthcare coverage in America, by no means the fearsome pariah its opponents are labeling it. But it’s not the paragon its proponents suggest it is, either. And for the tens of million Americans who it leaves in the dust, that means the same fear and anxiety I experienced when I didn’t have insurance—fear and anxiety that no one should endure.

Larkin Callaghan
Larkin Callaghan received her doctoral and master’s degrees from the Health & Behavior Studies department at Columbia, with a program focus in public health education and specialization in women's and adolescent health. Her research interests include social and behavioral epidemiology, women’s and adolescent reproductive health, health policy, and gender disparities (including among transgender and gender non-conforming individuals) in disease and access to care. She previously worked as a United Nations correspondent covering global health issues in developing countries, and currently manages Stanford University's global health education and training programs in developing countries. Follow her @LarkinCallaghan.

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Just checked your webpage. This article seems to be dated October 4, 2012.

I belong to a group of single payer advocates, supporters of Improved Medicare for All, and I want to cite this I want to cite this well written piece. Is there a date anywhere? I’m probably just missing it.


I found it interesting that nowhere in the political debates so far (at least nationally) have I heard much about how the ACAs leaves the millions of undocumented uninsured. This not only makes it harder for those populations to gain access to care, but the hospitals who have been supporting those undocumented immigrants will be dealt a huge blow, with the Disproportional Share Hospital funding getting cut because, presumably, there will presumably more fewer uninsured. Unfortunately this will not be the case, especially for hospitals such as Bellevue in NYC who will continue to serve a large population of undocumented immigrants.

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