The Affordable Care Act has been a lifeline for low-income and homeless people, but a Trump administration lawsuit could leave millions uninsured

By Gary Walker

This article was produced as a project for the USC Center for Health Journalism’s California Fellowship.

Cancer survivor Kenrick Bascom (left) and Dr. Jay Lee, one of the doctors who diagnosed him

When Kenrick Bascom lost his job as a finance officer at U.S. Bank at the start of the Great Recession in 2007, he also lost his health care coverage. After suffering from a consistent pain in his abdomen, the Venice resident was referred to the nonprofit community health center Venice Family Clinic, where he was diagnosed with potentially fatal kidney cancer.

Three blocks west of the clinic is Third Avenue, infamous for containing one of the Westside’s largest and most persistent homeless encampments. The block is often littered with tents, bicycles, RVs, forgotten dreams and broken spirits. That’s where “Jojo,” who did not want to give her full legal name, spends most of her time. Three years ago, on a chance visit to Venice Family Clinic, she learned that she had pancreatic cancer, which soon spread to her stomach.

Neither Bascom nor Jojo knew at the time of their respective diagnoses that it was Congress adopting the then-controversial Affordable Care Act that made them eligible for potentially life-saving surgery.

But if a Trump administration challenge to the Affordable Care Act is successful, low-income earners who lose their jobs and the homeless could be denied coverage and possibly life-saving medical procedures.

In July, Justice Department lawyers argued in federal court that the law should be invalidated because the mandate to purchase insurance under a state-run health care exchange has been eliminated.  Legislation passed in 2017 by the Republican-controlled Congress stripped out the financial penalties that most people would have been required to pay for noncompliance with purchasing low-cost insurance.

At Venice Family Clinic, doctors enrolled both Bascom and Jojo in Covered California, the state exchange under the Affordable Care Act.

“My surgeon told me that the cancer would have metastasized to other parts of my body eventually. I don’t know what other options I would have had without the Affordable Care Act,” said Bascom, whose surgery was performed at Keck Medical Center at USC.

Jojo’s also grateful for the Venice Family Clinic and for St. Joseph Center, a social services provider three blocks away from Third Avenue that provided additional help to her during her medical crisis.

“They’ve been like a dream for me. They helped me set up my appointments and found me a place to live so I could recuperate after my surgeries. I don’t know what I would have done without them,” said Jojo, a slim woman dressed in jeans and a gray T-shirt who wound up on Third Avenue after health care costs left her bankrupt.

“I’ve already had two surgeries, and now I’m down to just one more,” she said. “After that I’ll be cancer free.”

More than 20 million Americans — among them 5 million Californians — have gained access to health care coverage since the Affordable Care Act became law, according to the nonpartisan Henry J. Kaiser Family Foundation.

Prior to implementation, homeless adults could not qualify for Medicaid or Medicare unless they worked a set number of hours per month or if they could prove that they had a disability, were over 65, or pregnant, according to the Center on Budget and Policy Priorities, a progressive think tank that analyses how government policies impact the public.

States such as New Hampshire and Arkansas do not exempt those who are homeless from the work requirements. States like Kentucky limit the exemptions to six months, and in other states only the chronically homeless — typically a person who has been on the streets for five years or more — are excluded from the work requirement.

Adults with incomes up to 138% of the poverty line became eligible to enroll in a state exchange in states that accepted Medicaid expansion under the Affordable Care Act, regardless of disability and work status. Now the Trump administration is permitting states to take away medical coverage of residents who don’t work a certain number of hours, which could have a devastating effect on many of the working poor and the homeless, experts say.

“It will be rolling back the clock to a time when millions of people, including millions with preexisting conditions, could not get health coverage. There could very well be direct damage to any coverage for a huge portion of the population,” said Nadereh Pourat, a professor at the UCLA Fielding School of Public Health. “You’re talking about a situation where all those who gained coverage and were not covered before would now be losing coverage.”

Venice Family Clinic CEO Elizabeth Benson Forer agrees with Pourat about the potential ripple effect on those less fortunate and the entire health care industry.

“The number of people who would become uninsured again would be devastating. The Affordable Care Act has been in place for almost a decade. Without the Medicaid expansion, we would end up with all these folks who would now be uninsured, which could potentially cause a real collapse of our health care system,” she said.

The clinic reports serving more than 27,000 patients annually, about 4,000 of whom are homeless. Since the passage of the Affordable Care Act, the number of patients it serves has increased 34%, from 20,223 in 2014 to 27,136 in 2018.

Prior to the law’s passage, 25% of the clinic’s patients were covered by some form of insurance, including Medi-Cal. Since the Affordable Care Act became law, 75% of patients are covered by Medi-Cal.

Robert Brooks, 53, has been camping out in the Ballona Wetlands for several years and living on the streets for 12 years. Outreach teams from St. Joseph’s Center visit the encampment frequently but he rejects their overtures to visit a doctor. Brooks acknowledges alcoholism and that his health has deteriorated since his time on the streets. And though he recently acquired a Medicaid card, he prefers not to go to the hospital for heart murmurs and diabetes that have gotten worse since he became homeless.

“I don’t like hospitals because people die in hospitals,” he said.

Pourat says unchecked illnesses that linger for years, such as Brooks’ diabetes, could exacerbate an already alarming public health crisis.

“We could see more treatable illnesses such as diabetes, hypertension and other treatable conditions increase. If there are changes to the law the most vulnerable people will inevitably fall through the cracks,” she said. “You want a healthy community and a healthy workforce, and that doesn’t happen if you leave people behind.”

Jojo was largely unaware of how the Affordable Care Act impacts public health until her health crisis.

“I never really thought about it, but I’m glad that it’s there,” she said.

Bascom, who will celebrate five years of being cancer-free in December, wonders why politicians want to tamper with a law that has saved lives.

“I think it would be a great social injustice if we were to dismantle it,” he said. “Without the assistance of the doctors at Venice Family Clinic and the Affordable Care Act, I would not be alive today.”