Kentucky, West Virginia among states that would be hit hardest by an ACA rollback

A federal judge’s decision striking down the ACA that is still pending a legal review would have significant implications for insurance access and healthcare spending should it ultimately take effect, according to a new report. 

States that significantly grew their insured populations under Medicaid expansion would face the greatest coverage losses, according to a new report from the Urban Institute.

Kentucky, for example, could see its uninsured population grow by 151%, and West Virginia could see its uninsured rate go up by 176%. Overall, the report estimates that 19.9 million people nationwide would lose coverage, increasing the uninsured population by 65%. 

Linda Blumberg, an institute fellow and one of the report’s authors, told FierceHealthcare that rolling back reforms as widespread and complex as those in the ACA would be a time-consuming, complicated process that touches all areas of the healthcare system. 

“It’s not a simple task to fully set back the clock to where we were before,” Blumberg said. “The implications of doing that are quite vast.” 

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A Texas judge ruled in December that the ACA was unconstitutional, arguing that Congress’ appeal of its individual mandate invalidated the entire law. That ruling faces a long legal path, and the law has remained in place as the appeals process plays out

Seven states—Arizona, Delaware, Hawaii, Massachusetts, New York, Vermont and Wisconsin—had negotiated Section 1115 waivers for expansion before 2010. But with the full rollout of the ACA in 2014, most adapted their Medicaid programs to meet the law’s options versus the previous waivers. If the ACA is repealed, these waivers would need to be renegotiated, with uncertain results. 

An ACA repeal that also eliminates these programs has significant implications for uninsured rates in those states, according to the report. In Massachusetts, for example, 102,000 people would lose coverage should the ACA be rolled back. If the waiver is also eliminated alongside the ACA repeal, that number jumps to more than 338,000 people, or a 245.9% increase in the state’s uninsured population. 

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“It’s quite unclear what would happen in these states if the Affordable Care Act was found to be invalid,” Blumberg said. 

Repealing the ACA would also lead to a major decrease in federal and state healthcare spending. Eliminating the law would cut $82.2 billion in spending on Medicaid and the Children’s Health Insurance Program, alongside ending $52.2 billion in tax credits and reinsurance spending. 

In 15 states, federal healthcare spending would decrease by 40% or more, according to the report. State spending on Medicaid and CHIP would also decline by $9.6 billion, or 5.7%. 

Blumberg said there are policy analysts and experts who would interpret that as a positive result, as it saves the government money. However, she warned that these spending cuts would disproportionately impact vulnerable rural and low-income populations. 

“I think it’s important to talk about the government spending and not just go, ‘Oh, savings are savings,’” she said.