By expanding care and coverage, the Affordable Care Act was a milestone for communities most underserved by the health system. In particular, the ACA includes a number of provisions that improve coverage and access to care for people with disabilities and/or complex health care needs. These improvements in coverage are a critical foundation for a movement toward patient-centered policies, sustainable long-term care and quality primary care. 

One of the most widely known benefits of the law are protections for people with pre-existing health conditions – which includes anyone with a disability and/or complex health needs – from being denied or charged more for coverage. However, the ACA had huge impacts for people with disabilities that go beyond pre-existing conditions protections, especially for those who are eligible for both Medicare and Medicaid coverage. The ACA’s infrastructure and legal protections are at the core of health coverage for the disability community. The ACA’s Medicaid expansion provided a pathway to eligibility for people with disabilities who previously had been excluded from coverage, by lifting income limitations and expanding eligible health conditions.

The ACA made important strides in long-term services and supports (LTSS), a critical category of health care for people with disabilities and older adults. One part of LTSS is home and community-based services (HCBS), which are supports that enable people with disabilities to remain integrated and independent in the communities of their choosing. Over the past few decades, HCBS have enabled disabled people to transition back into the community after living in institutional settings. This shift towards community-based settings is the result of disability advocates pushing for deinstitutionalization and was solidified by the ACA. The ACA’s expansion of Medicaid and LTSS programming has allowed more people to access the LTSS they need to live in a community setting. Due to the ACA’s creation of more opportunities to divert LTSS away from institutional settings, states have increasingly focused their LTSS funding on more community-based settings.

Since 2013, HCBS expenditures have made up the majority of LTSS spending and continue to increase each year. The 2022 policy priorities of Congress and the Biden administration provide opportunities to build upon the ACA’s legacy of HCBS expansion. In particular, President Biden’s remarks at the State of the Union in support of a $150 billion investment in HCBS mark an encouraging path forward.

Another critical way the ACA incorporated innovation into law was through the provision known as the “No Wrong Door” policy. This policy is meant to allow people seeking health care coverage to fill out one application and let the government determine how needs align with other safety net programs, eliminating subsequent and repeated applications. Center partners Massachusetts Senior Action Council (MSAC) has made it part of their mission to Close the SNAP Gap – the gap between low-income residents receiving MassHealth (Medicaid) who are likely also eligible for the federal SNAP (food stamp) program and those who actually receive SNAP. Over 700,000 residents receiving MassHealth are missing out on this key food assistance program, including 100,000 seniors.

Because of the engagement by MSAC members, $5 million was secured in the IT Bond Bill to enable MassHealth and Medicare Savings Program Applicants to apply for SNAP at the same time and engaged the governor to include $1 million in proposed FY 21 for a unified system to advance the No Wrong Door approach. Additionally, the Department of Transitional Services and the Executive Office of Health and Human Services committed to publishing the first MassHealth streamlined application for seniors (new enrollees only) that included an application for SNAP benefits and to extend integrated applications to current enrollees for recertification. These advancements will go into effect this summer, and will disproportionately benefit low-income seniors who are more likely to be women and people of color.

Expanding HCBS funding and eligibility is critical to ensure every person with a disability has access to the services and supports they need to thrive. Doing so would realize the original intent of the Affordable Care Act and continue its legacy as a legal safeguard for the disability community.