WHY UPHOLDING AND BUILDING UPON THE AFFORDABLE CARE ACT (ACA) IS A HEALTH EQUITY ISSUE

By Renata Schiavo

This blog post first appeared on December 4, 2024 on The Communication Initiative (The CI). We are grateful to The CI for hosting this post and for their permission to reproduce it here.

 "Of all the forms of inequality, injustice in health is the most shocking and the most inhuman..." - Dr. Martin Luther King, Jr., March 25, 1966
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Dr. King's powerful words still resonate in today's health equity movement across issues that contribute to health, racial and social inequities. Many scholars and professionals have rightly pointed that this quote "makes clear his moral concern beyond health care alone", given Dr. King's "unfailing attention to poverty, racism, education, and housing - what we now often call social determinants of health". (1)

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In fact, there are many barriers that prevent people from leading healthy and productive lives. Inequities in access to healthcare are among them. Equal access to quality, culturally relevant, and bias-free healthcare services is an important social and political determinant of health. This is also a crucial human right, which affects issues of life or death in our communities.

As an immigrant, a woman, someone who grew up with very modest means, a family caregiver for most of my life, and a foreign-born American citizen, I continue to be surprised by the many inequities in the U.S. [United States] healthcare system.

I grew up in Italy, a country where universal healthcare coverage guarantees that everyone - and I mean everyone - has equal access to healthcare. Is this system perfect? No, it's not, and it would be naïve to believe that any healthcare system might be perfect given the complexity of the types of services being provided as well as the increasing need for complex medical care often caused by increasing economic, racial and social inequities. Italy and many other countries, including the United States, have a lot to learn from each other, as well as to continue to address inequities related to differences in quality of services, limited cultural humility, and/or implicit or institutional bias toward specific groups and communities.

Since its inception in 2010, now almost 15 years ago, the Affordable Care Act (ACA) has been a historic tool to advance health equity in the United States, and to expand access to healthcare for millions of American citizens. Over the years, I have been celebrating with many others in our community this important milestone in our country's history. Not only has the ACA provided much-needed healthcare access to millions of people but it has also mandated several provisions that gave institutions and leaders a long-awaited framework to reflect on their practices, and address inequities in the healthcare system. For example, the ACA requires healthcare providers and their institutions to assist patients with limited reading skills, as well as highlights the importance of cultural and linguistic competence to identify patient barriers to care and promote inclusive clinical environments (2,3). 

It also bans discrimination against patients, and their families and caregivers, as related to "race, color, national origin, sex, age, or disability", and other socially determined factors (2,3). 

So, how does the ACA directly impact health equity? By now in its second decade, the ACA has reduced inequities in healthcare coverage and expanded opportunities to seek medical care for millions of Americans. The Center for Budget and Policy Institute, a nonpartisan research and policy organization, reported in March 2024 that "as of the end of open enrollment, 21.4 million people have selected an ACA marketplace plan for 2024, and 40 states and the District of Columbia have expanded Medicaid. The number of people who are uninsured has dropped from 45.2 million in 2013 to 26.4 million in 2022, a historic decline.” (4)

Moreover, and always mind boggling for me, the ACA has restored the freedom of millions of Americans who live with pre-existing conditions to look for a new job, without the fear of being denied healthcare coverage for themselves and their families if the healthcare insurance provider of any future perspective employer were different from the one that currently covered them. This is something that could happen before but not under the ACA. Now, if we think of one essential freedom, there is nothing more important than advancing one's dreams, careers, economic opportunities, and ability to provide for one's family and loved ones. Think of this...think about the kind of professional freedom to move jobs the ACA provided to the many people living with diabetes, cancer, anemia, eye disease, and many other chronic conditions. These are our family members, our friends, our neighbors, the people we love and want to do well.

Is the ACA perfect? No, it's not. Again, it would be naïve to believe it is. Is this a wildly successful step forward? Yes, it is. It's an important landmark law that was designed (a) to improve the health of each and all Americans, and (b) to provide a framework to continue expanding on healthcare services and information that ultimately allows people to stay healthy and prevent and treat disease.

The ACA has significantly contributed to the most fundamental human right: the right to health and to be taken care of when we are sick. Being healthy is foundational to all other kinds of human rights at all times. It allows people to have the strength, and physical and mental fitness, to raise kids, to move to a new city, to connect with social opportunities, and/or to secure the jobs we want. Access to healthcare, which the ACA has greatly expanded, is essential to achieving the right to health.

Upholding and building upon the Affordable Care Act is a health equity and human rights issue. If you are part of the health equity movement, make sure to continue to inform your constituencies about the ACA and advocate for it. We cannot go back! #actforhealthequity

In solidarity and strength.

References:

1. Galarneau, C. (2018) "Getting Martin Luther King's Words Rights". Journal of Health Care for the Poor and Underserved, Johns Hopkins University Press, February 2018. Excerpts available on the Physicians for a National Health Program (PNHP) website.
2. U.S Department of Health and Human Services. Section 1557 of the Patient Protection and Affordable Care Act. Available here
3. Centers for Medicaid and Medicare Services | CMS.gov. Course 7: Cultural Competence and Language Assistance. Available here [PDF].
4. Sullivan, J, Orris, A and Luken, G (2024). "Entering Their Second Decade, Affordable Care Act Coverage Expansions Have Helped Millions, Provide the Basis for Further Progress. Center on Budget and Policy Priorities, March 25, 2024". Available here.

Image credit
Ted Eytan via Flickr (CC BY-SA 2.0)

Disclaimer
The views and opinions expressed here are those of the author only and do not necessarily reflect the views and positions of any of the organizations/entities with which the author is affiliated. Organizations listed in the author's profile on The CI site are included for identification purposes only. No endorsement of the author's opinions in this blog post by any of these organizations/entities is implied here.

​Author’s Bio
Renata Schiavo, PhD, MA, CCL is the Founder of Health Equity Initiative, and serves on the organization's Board of Directors as its President. Dr. Schiavo is a passionate advocate for health equity and a committed voice on the importance of addressing and removing barriers that prevent people from leading healthy and productive lives. She is a senior lecturer at Columbia University Mailman School of Public Health, Department of Sociomedical Sciences, and a principal at Strategies for Equity and Communication Impact (SECI), a global consultancy. She is the Editor-in-Chief of the Journal of Communication in Healthcare; Strategies, Media, and Engagement in Global Health and serves as senior editor of the Journal of Health Equity and on the editorial board of Health Equity. She has significant experience across public health, healthcare, global health and international development.