The Affordable Care Act is an important protection that supports care for the disability community. In this ongoing blog series, we will dive deeper into our policy work for 2025. This post is being released as 90% of the ACA Navigator workforce is facing layoffs, and drastic changes to the ACA are being proposed. Our last post focused on the importance of Medicaid. Follow our Policy Updates and the Disability & Public Health Newsletter to stay on top of our current advocacy on these issues.
Defending the Affordable Care Act
The Patient Protections and Affordable Care Act or “ACA” passed in 2010. This launched the Health Insurance Marketplace through Healthcare.gov in 2013. This program is sometimes referred to as “Obamacare”. This law took on disability-related disparities in healthcare access. The ACA made it easier for individuals to get health coverage. It also provided tax credits to help offset the cost of monthly premiums. This allowed most families and individuals to find a plan at a price that was more affordable. This bill also stopped health insurance companies from discriminating against people with disabilities. Before the ACA, people could be denied care for “pre-existing conditions”. These people simply had greater healthcare needs. The ACA prevented insurance companies from pricing people out of the market. It eliminated the practice of medical underwriting. This is when an insurance company sets a person’s healthcare cost based on their medical history. The ACA also required essential health benefits for all plans on the Marketplace. The goal was to ensure basic needs are met for all.
As we enter this new administration, we expect challenges to the Affordable Care Act. Over 44 million people receive health coverage under the ACA and Medicaid expansion. This is about 1 in 6 people under 65 years old. When the ACA passed, an estimated 3.5 million people between the ages of 16 and 65 with pre-existing medical conditions or disabilities were uninsured. The ACA is an important policy we’re tracking and defending in 2025. Here are the critical ACA protections that impact coverage for people with disabilities:
Ensuring coverage regardless of disability or health status
“Pre-existing conditions” were once a reason to deny people needed coverage and care. Insurance companies would reject applicants with higher health needs. Sometimes companies would limit coverage or charge people higher rates. With the passage of the ACA, Americans gained access to fair coverage. This had once been denied to many, including people with disabilities. One of the more well-known and popular provisions of the ACA is called “Guaranteed Issue”. It required insurance companies to cover all individuals who apply for coverage. People could not be denied coverage for their health or disability status. This includes a guaranteed renewability of coverage. Insurance companies cannot cancel someone’s plan just because they access more care. Before the ACA, this is what might have happened for simply acquiring a health condition. Protections for people with disabilities and other chronic medical conditions are important. They allow people to both begin coverage and maintain it.
Ensuring affordable coverage without monetary caps
Having coverage alone is the first step to accessing care. However, health insurance companies pre-ACA could still determine a person’s premium based on their health status. This practice is called underwriting. The ACA made sure that guarantees of coverage and renewability meant something. Prohibiting the practice of individual underwriting made care possible. The ACA also required insurance companies use a community rating system to set insurance prices. This averages out the expected health costs in a geographical pool. That ensures all enrollees in an area aren’t charged more based on their health status. Individual enrollees won’t be priced out of the market when buying health insurance.
The ACA required companies to ensure that enrollees are covered for life. Coverage can’t change due to service usage. The ban on lifetime and annual coverage caps ensures people aren’t at risk of losing care. They do not need to worry about their benefits running out when they reach an arbitrary amount of care used.
Ensuring comprehensive coverage
Under the ACA, there was a minimum standard of care that plans had to offer to be included on the Marketplace. The requirement of Essential Health Benefits (EHBs) extends the prohibition against medical underwriting. Insurance companies can’t charge more because someone has complex health care needs. Prior to the ACA, there were many people whose insurance didn’t cover their care. This included things like maternity care, and substance use or mental health treatments. Some people lacked coverage for prescription drugs. Of the ten Essential Health Benefits, many are essential for people with disabilities. Services and devices for people in rehabilitation and habilitation are covered. These allow a person to access therapies that support day to day function. These supports help people who are born with a disability or become disabled later in life.
People with mental health disabilities continue to experience higher uninsurance rates. Meeting the health needs of this population continues to be a priority. The ACA expanded protections in the Mental Health Parity and Addiction Equity Act. Individual or small group insurance plans now need to cover mental health treatments. This essential care includes medications and other therapies. These are essential supports for people with psychosocial disabilities.
Ensuring accessibility of care
Health coverage alone may not ensure access to care for people with disabilities. Under the ACA, additional protections were required to ensure care use. Last year, protections against healthcare system discrimination were updated. These were outlined in the updated Section 1557 rules of the Affordable Care Act. Access to ASL interpretation and alternate formats were made possible for provider visits. Any new health facility construction also needed to meet basic accessible design standards. These protections are now under scrutiny. A new Executive Order calls for a revision of the regulations. This order undermines ACA protections for transgender people accessing healthcare. There have been many recent attacks on DEI across the federal government. This includes instructions to censor research. The protections under 1557 may be subject to a much more comprehensive rewrite.
The rules for Section 504 of the Rehabilitation Act were also updated in 2024. These guidelines prevent discrimination of people with disabilities in health and human services. This clarifies the original protections against discrimination in all government funded programs. This impacts any provider who accepts public funding through Medicare or Medicaid. Through these regulations, care decisions could not devalue people with disabilities. Access requirements were set for medical equipment and healthcare delivery. All digital spaces needed to meet WCAG standards. They also advanced community integrated living for people with disabilities. Right now, 17 states are challenging these rules. The lawsuit Texas v. Becerra is an attempt to get rid of Section 504. This loss would harm our community.
Coverage for All
About 1.4 million Americans don’t have any options for health coverage. These people fall into a coverage gap. Without employer-sponsored health insurance, they would need a public insurance option. However, they don’t qualify for Medicaid and aren’t making enough to afford an ACA plan. This coverage gap affects people living in states that refused to adopt Medicaid Expansion. Medicaid expansion aimed to offer coverage for individuals making up to 138% of federal poverty line (FPL). After the ACA passed many states refused to expand their Medicaid programs. People with incomes between 100-400% of FPL could get affordable Marketplace plans. People in non-Expansion states making less than 100% FPL were unable to receive ACA subsidies to buy a plan. They also were unable to apply for their state Medicaid program. These often had rigid eligibility criteria. This meant that coverage was not available to many people below 100% of FPL. There are now 10 states where this is still true.
This can affect coverage for many people with disabilities. Approximately 20-30% of people covered through Medicaid expansion have a disability. There are likely more people with disabilities in this coverage gap. Some people might struggle to get proper documentation of their disabilities. This is a challenge for those with certain chronic conditions like Long COVID. Chronic conditions affect the ability to work and access employer-sponsored health insurance. We must defend and expand coverage under the Affordable Care Act. This is one path to making sure all people with disabilities receive the care they need.
By the end of 2025, the Enhanced ACA subsidies are set to expire. These have been essential for increasing affordability of healthcare. These need to be extended to ensure that premiums don’t spike for Marketplace enrollees in 2026. Premium tax credits have reduced costs by over $700 annually for the average enrollee. The cost to enrollees could increase by estimates of as much as 93% if these expire. This would cause millions of people to drop coverage. These tax credits have helped to lower out-of-pocket costs for enrollees. They’ve also increased enrollment among Black and Latino Americans. We will follow these policy developments throughout the year to ensure that care needs don’t go unmet for our communities.
At the time this blog is being released, new regulations are being proposed that would undercut the protections in the ACA. Follow us for more updates on these developments in our work to ensure adequate coverage for people with disabilities.