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Nearly a decade after the Affordable Care Act (ACA) was first passed, and weeks before a potential court decision threatens the law’s future, evidence is growing that the ACA is making Americans healthier and has saved thousands of lives.

The Washington Post recently reported on a series of studies finding that the groundbreaking 2010 healthcare law has had profoundly positive effects, particularly in states that expanded Medicaid. 

The ACA has expanded health coverage and made people healthier

The Post focused specifically on Michigan, where poor people with asthma and diabetes experienced fewer hospital visits after the state expanded Medicaid to about 650,000 people under the ACA. A 2017 study also found that patients who had cardiac bypasses or valve surgeries in Michigan experienced fewer complications compared to similar patients in Virginia, which didn’t expand Medicaid until 2018. 

In general, states that expanded Medicaid had better health outcomes compared to those that didn’t. Patients with advanced kidney disease who went on dialysis were more likely to still be alive a year later if they lived in a Medicaid-expansion state, and Ohio’s Medicaid expansion helped more than 25,000 smokers quit smoking. 

A 2018 study also found infant deaths, especially among black babies, decreased more dramatically in Medicaid expansion states than in other states, though the study doesn’t distinguish which families got coverage through the ACA expansion.

Meanwhile, a National Bureau of Economic Research paper from July that examined all deaths among adults from their mid-50s to mid-60s, found that dying in a given year was significantly less likely in states that expanded Medicaid.

Arizona also has seen significant benefits thanks to ACA expansion. In 2013, the year before the ACA went into effect, there were more than 1.1 million uninsured people in Arizona, or 18% of the state’s population, according to the U.S. Census Bureau. By 2016, the number of uninsured had dropped to 681,000, a 39.1% decrease. 

This sharp decrease came in part due to the state’s 2013 expansion of Medicaid, which allowed more than 400,000 Arizonans to sign up for coverage. 

After years of decreases to its uninsured rate, the number of Arizonans without coverage actually increased in 2018, which experts say is at least partially due to President Trump’s efforts to undermine the ACA. Since sweeping into office in 2017, the Trump administration cut back on advertising and enrollment assistance for the healthcare marketplace and effectively repealed the ACA’s individual mandate.

Republicans are suing to end the ACA (again)

The next big threat to the ACA is a federal lawsuit, brought by 20 Republican-led states, including Arizona, that challenges the law’s constitutionality. 

The suit was filed in 2018, shortly after Republicans passed their tax bill essentially repealing the individual mandate, a provision of the ACA that was intended to push people to purchase health insurance in order to lower costs for Americans with chronic illnesses. If people opted not to purchase insurance, they had to pay a penalty.

Republicans previously challenged the individual mandate in court, but it was upheld by the Supreme Court in 2012 in a 5-4 decision that ruled the individual mandate was indeed constitutional under Congress’s taxing power.

While they lost the case in 2012, Republicans, including U.S. Sen. Martha McSally (R-Ariz), were finally able to gut the individual mandate in 2017, when they voted for their tax bill, which reduced the penalty for not purchasing insurance to $0.

This opened the door for Republican states to file their lawsuit, and they are now arguing that because the individual mandate — which had been upheld by the Supreme Court as a tax — no longer had a penalty, then it was no longer a tax, thus making it unconstitutional.

But the Republican state attorneys general behind the lawsuit, including Arizona’s Mark Brnovich, aren’t stopping there. They’re also arguing that if the individual mandate is declared unconstitutional, then the entire ACA should be struck down as well, or as the lawsuit itself puts it: “Once the heart of the ACA — the individual mandate — is declared unconstitutional, the remainder of the ACA must also fall.”

A trial court judge in Texas sided with the Republicans and struck down the entire law in 2018, but the case was appealed to the U.S. Court of Appeals for the 5th Circuit, which is expected to make a decision in the coming days. Should the appeals court uphold the lower court’s ruling that the law is unconstitutional, the ACA could wind up before the Supreme Court yet again.

What ACA repeal would mean for Arizona

If the ACA were repealed, 297,000 Arizonans would lose their health insurance, leading to a 38% increase in the state’s uninsured rate, according to Protect Our Care, a group focused on protecting healthcare.

Repeal of the ACA also would leave the nearly 2.8 million Arizonans who live with a pre-existing condition — such as asthma, diabetes and cancer — without patient protections, meaning insurance companies could once again deny them life-saving coverage. This includes 386,200 children, according to FamiliesUSA, a nonprofit, nonpartisan advocacy group for healthcare consumers.

During a recent “tele-town hall,” Sen. McSally said that protections for Arizonans with pre-existing conditions would not go away, even as the health care repeal lawsuit looms on the horizon. 

This has been a common refrain for McSally since she launched her failed 2018 campaign for Senate. She has also repeatedly — and falsely — claimed that she was “leading the fight” to “force insurance companies to cover pre-existing conditions,” when in reality, she voted for a full repeal of the ACA in 2015, which would have meant the loss of protections for people with pre-existing conditions. 

She also voted to repeal and replace the law in 2017, infamously telling her colleagues they needed to get the “f-cking thing” done. The bill she voted for, the American Health Care Act (AHCA), would have weakened protections for people with pre-existing conditions, according to health experts. 

Regardless of where McSally stands now, should Republicans’ lawsuit achieve its goal and lead to ACA repeal, it would almost guarantee a surge in the uninsured rate in Arizona.

Beyond that, if the Post’s recent reporting and a growing list of studies are any indication, ACA repeal would also cost lives and lead to worse health outcomes across the country.