This year, the best way to promote breast cancer awareness may be by voting.
With the Supreme Court set to hear arguments in Texas v. California — which challenges the constitutionality of the individual mandate in the Affordable Care Act (ACA) — an estimated 20 million Americans stand to lose their health insurance. A repeal of the act would also affect millions of Americans with private insurance whose coverage is guaranteed by the ACA despite pre-existing conditions.
The challenge, which is being brought to the courts by Republican States’ attorneys and with the support of the Trump administration, is just one of the many ways that Trump, and the Republican party more generally, have sought to undermine not only health care but access of care for LGBTQ+ people, women, low-income earners, and minority groups.
When enacted, the ACA effectively transformed the landscape for healthcare in the United States. Essentially, the law guaranteed that more Americans could have access to affordable healthcare regardless of their income or any pre-existing conditions.
“It removed the ability of insurers to discriminate based on age and gender preferences,” says Dr. Johnathan Gruber, professor of economics at MIT and a consultant in the Obama administration who helped craft the ACA. “We ended the ability of insurers to discriminate. This often goes under the rubric of pre-existing conditions, but it’s not just pre-existing conditions; it’s really just broad discrimination. Women used to pay more than men for health insurance. Basically, that’s ended.”
For those who’ve been diagnosed with, or are at risk for, breast cancer, the ACA guarantees that screenings and certain preventative treatments are covered by both private insurance and Medicaid and Medicare at no cost to the patient. Guidelines set by the United States Preventive Services Task Force (USPSTF) and the Health Resources and Services Administration (HRSA) require that private insurance plans, as well as Medicaid expansion, cover mammogram screenings (every one to two years for women over 40), genetic testing and counseling for certain high-risk patients, and preventative medications for certain women with “elevated risk,” as reported by the Kaiser Family Foundation (KFF).
Research has shown that access to insurance correlates to whether or not women will get screened for breast cancer. According to the KFF report, in 2015, only 30% of uninsured women reported undergoing mammograms compared to 72% of women with private insurance and 58% covered by Medicaid.
Should the ACA be repealed by either a Supreme Court ruling or by a gradual chipping away by Republican lawmakers, the protections which it baked into the healthcare system will no longer apply. The Human Rights Campaign estimates that as many as 130 million Americans with pre-existing conditions could lose coverage or face annual limits on care, including those with employer-sponsored insurance.
“Fundamentally, insurers will go back to being able to discriminate against people,” Gruber tells GO.
The Trump administration’s attempts to limit, if not repeal, the ACA appear to have gone hand-in-hand with limits imposed upon access to healthcare information, specifically those affecting minority groups and women. As early as 2017, the Department of Health and Human Services (HHS) began removing information on its website that pertained to sexual minorities, persons of color, and non-English speakers. The breast cancer page, housed on the HHS’s Office on Women’s Health (OWH) website, was one of those affected. A report by the Sunlight Foundation found that “informational pages and factsheets about the disease, including symptoms, treatments, risk factors, and public no-or-low-cost cancer screening programs, have been entirely removed.” Included in the removed information were provisions of the ACA that require no-cost screenings and links to free screening programs.
At the time, representatives from the HHS claimed the information removed was “not mobile-friendly and very rarely used.” However, given the Trump administration’s frequent attacks on the ACA — as well as the co-current removal of information pertaining to lesbian and bisexual health, and later, the Denial of Care Rule provisioned into the ACA, allowing medical caregivers to deny service on religious grounds — have led critics to conclude that the removal was part of a larger campaign to undercut both the ACA and access to health-related information.
The Denial of Care Rule was one of the more obvious attempts to undermine the protections brought by the ACA to healthcare access and serves as a harbinger for what could be in store should SCOTUS strike down the ACA or the current administration and lawmakers go unchecked in their efforts to undermine the act. For LGBTQ+ people, and specifically transgender persons, the consequences could literally be deadly.
“It’s kind of hard to understand all the different ways that [a repeal] could manifest itself, but I do fully anticipate that we will see an exact reversal of some of those protections that we had,” says Scout, the Executive Director of the National LGBT Cancer Network. Some of the reversals are already apparent in the erasure of transgender persons and LGBTQ+ protections within the administration.
“I think probably the bigger challenge in all this would be something that’s a little insidious because it will be hard to measure, and that’s this dog-whistling to providers that it’s okay to discriminate,” Scout tells GO. “Because, whenever any of us experiences one of those bad-provider interactions, it echoes around our social circle. It cumulatively means that we avoid healthcare. And that, ultimately, particularly with cancer, really hurts us, because if you’re not getting those screenings, it’s not going to be found until later, and your survival chance is going to drop.”
By contrast, the ACA as originally implemented offered protections that previously were unheard of for transgender persons. For example, Scout tells me, someone who is a man of trans experience and who identifies as “male” on a medical checklist might have been denied coverage for treatment affecting biological female parts; however, under the ACA, such treatment is now covered. (Both trans men and women are at risk for breast cancer and should be screened regularly.)
“[The ACA] really changed the world for trans people,” he says, “because it meant that you couldn’t deny that care simply because we’re trans and it didn’t fit into your A or B check boxes.”
Rhetorically speaking, efforts to repeal the ACA are often accompanied by pronouncements to replace it, allowing individuals to still have access to affordable healthcare under some other plan. In recent months, President Trump has issued a number of executive orders which call for affordable healthcare access, including low-cost prescription drugs and coverage for pre-existing conditions. However, as reported by Kaiser Health News and Jon Greenburg, the orders lack content and offer no path forward to ensuring affordable healthcare access. They fall far short of the guarantees provided by the ACA.
“They are all words, no actions,” says Dr. Gruber. “They are literally [saying], ‘We will protect pre-existing conditions.’ It doesn’t say how.” Despite saying since its inception that they would both repeal and replace the ACA, Republicans “have yet to come up with a replacement.”
But the fate of the ACA is hardly set. Even if the Supreme Court were to strike down the law, it could still be saved, but only if Democrats take back the White House and the Senate. Should they, Gruber says, all they would have to do is remove the individual mandate — the lynchpin for the recent Republican challenge in Texas v. California — from the existing law.
“But unless the Democrats get both the Senate and the Presidency,” he says, “there’s a risk that the whole law could go down.”
If you, or someone you know and perhaps even love, has, has ever had, or may ever be diagnosed with breast cancer, the best way you can show them your support isn’t with a pink ribbon but with a ballot.