Ask a dozen civil rights lawyers to name the great civil rights laws of the last 100 years, and you’ll get a dozen answers. Some might name the Civil Rights Act of 1964, the landmark law which ended segregation in public places and barred discrimination on the basis of race, sex, color, religion, or national origin at work and in other public places. Others might point to the Fair Housing Act, which took aim at dismantling entrenched residential segregation and fighting housing discrimination. Still others might highlight the Americans with Disabilities Act, which paved the way for a more accessible world.
What few people might include in the list, but should, is the Affordable Care Act of 2010, the law that made health insurance — and with it, health care itself — accessible to millions for the first time. It earns its place as a great civil rights law for several reasons: It bars certain forms of discrimination; it begins to address effects of longstanding discrimination; and by providing coverage for the health care all people need, it enables the freedoms other civil rights laws aim to protect. Simply put, it is not possible to fully participate in the economic, social, and civic life of our nation without stable health coverage.
But the Affordable Care Act is now imperiled. This week, the Supreme Court will hear arguments in California v. Texas — a case that puts this critical law in jeopardy of being struck down in its entirety. While most legal scholars think such a ruling unlikely, any decision striking the law would have devastating ramifications for the civil liberties advancements that the ACA has provided. And it would have particularly cruel and deadly consequences in the midst of a pandemic and recession. Dismantling the ACA now would exacerbate the longstanding, systemic disparities in access to health care, economic opportunities, and other resources faced by Black, Latinx, and disabled people in this country — disparities that are now approaching epic proportions in light of the pandemic.
The Affordable Care Act made huge advancements for many groups of people to whom stable health insurance and health care were often denied, whether because of express discrimination or the effects of discrimination.
Women: The ACA bars sex discrimination, full stop. This means, for example, that at long last insurers may no longer charge women higher rates. The ACA as implemented covers care long excluded from insurance coverage that was seen as exclusively women’s care: mammograms, screenings for cervical cancer, contraception coverage and counseling, lactation support, and prenatal care. These forms of discrimination had material consequences. Before passage of the Affordable Care Act, women were estimated to spend 68 percent more than men in out of pocket health care costs. The ACA takes aim at discrimination that perpetuates gender inequity, including the discrimination in health care that perpetuates gender disparities in wealth.
The ACA is part of the path to equity — remedying systems of oppression and discrimination — that runs to the core of living or dying, particularly during the time of COVID-19.
LGBTQ people: The ACA’s bar on sex discrimination also means that LGBTQ people can’t be subject to discrimination in federally funded institutions, public health care programs, or by insurance companies. The ACA eliminates barriers that many LGBTQ people previously faced in receiving health care — a crucial step toward ensuring health care is accessible to all — regardless of gender identity or sexual orientation.
People of color: The ACA makes important strides to address racial injustice in health care as well. It bars discrimination based on preexisting conditions, a provision critical to ensuring that those who are sick — and thus most in need of health insurance — aren’t effectively barred from accessing it. While this provision is important to people of all races, it is also an essential part of beginning to redress the health disparities that reflect the legacy of race discrimination in the country. This is evident in the higher rates of hypertension among Black people, for example, and the disproportionate rates of COVID-19 infections and deaths among Black and Latinx communities.
The data is striking: Because of the ACA, between 2013 and 2017, the coverage gap between Black and white Americans declined from 11 to 5.3 percentage points. Similarly, during the same period, the coverage gap between Hispanics and non-Hispanic whites dropped from 25.4 to 16.6 percentage points. Additionally, the ACA expanded Medicaid for people whose income is below 138 percent of the federal poverty level. In short, the ACA has helped make important strides in reducing racial, ethnic and economic disparities in in access to health care and coverage.
People with disabilities: The ACA has been a life saver for people with disabilities. It protects against coverage limitations based on preexisting conditions or lifetime limits, and guarantees coverage of services for mental illnesses and developmental disabilities. It provides access to long-term, home-based health care, which can mean the difference between institutionalization and independence for people with disabilities. And it expressly precludes discrimination in access to health care based on disability.
People experiencing poverty: The ACA also expanded Medicaid for people up to 138 percent of the federal poverty level — although not every state availed itself of the option, despite its literal life-giving opportunities. Prior to the ACA’s passage, Medicaid eligibility for parents was limited to those with very low incomes (often below 50 percent of the poverty level), and adults without dependent children were ineligible under federal rules, regardless of their income level, according to a report from the Kaiser Family Foundation.
The ACA is part of the path to equity — remedying systems of oppression and discrimination — that runs to the core of living or dying, particularly during the time of COVID-19. As we said in our 2012 brief, the ACA “advances the twin goals of liberty and equal protection.” The ACA is worth fighting for. Our civil liberties and civil rights are worth fighting for.
Louise Melling, Deputy Legal Director and Director of Ruth Bader Ginsburg Center for Liberty, American Civil Liberties Union.
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