The U.S. Supreme Court will hear arguments in California v. Texas on Tuesday. This case challenges the constitutionality and validity of the ACA. It is possible that Mississippians could be affected if the case is not ruled out. Women in particular will lose their access to preventive care such as prenatal care and birth control. They also have protections that protect them from having to pay more for routine care. This was a common practice prior to the ACA. Open enrollment for next year’s coverage begins. Enrollment counselors have put the unknown fate of the law in their minds and are moving forward with enrollment. They cite COVID-19 to ensure that as many people as possible are covered. After a dip in enrollment nationwide in 2017, the ACA rolls have seen a rise in recent years. 91,000 Mississippians use the ACA Healthcare Marketplace each year to purchase their health insurance. The marketplace is used by 60% more women than men, and 54% of all Mississippians. Black Mississippians have seen a 35% drop in their uninsured rates since 2008 thanks to ACA insurance signing-ups. This compares with a 27% decline for the state. The law could be invalidated and Mississippians without insurance could rise to 450,000. This would erase the gains made in the past decade. Pre-existing conditions, including COVID-19, that has disproportionately affected women and Black Mississippians, could lead to more charges or even denial of coverage. Research has shown that 3 million people lost their employer-sponsored coverage because of COVID-19 job loss. However, large insurance losses were mostly offset by state and federal programs like Medicaid and ACA. Popularity of the law’s patient protections is high across all political parties. Favorability has grown over time as policy norms have been established. According to research by the Center for Mississippi Health Policy, the main provisions of the law were favored by the majority Mississippians in 2017. Although Mississippians are still not well-versed in the law’s details, they seem to have learned a lot about it. The law was not popular in Mississippi in 2013 and 2015. However, more Mississippians favored the law in 2017 than a negative opinion. Zach Smith, who specializes on health law at the Center for Mississippi Health Policy, said that the majority of Mississippians didn’t like the law in 2015 and 2013. Smith stated that although it was impossible to determine what changed Mississippians’ opinions about the ACA, it is possible that people started to understand core provisions and their liking for the law. Smith also mentioned other provisions of the law related to public health and prevention that are less well-known but work in the background to make communities healthier, such as premium rebates, smoking cessation, and nutrition labeling. The law’s patient protections have been particularly beneficial to women and they tend to support it. Certain essential health benefits such as prenatal care, birth control, and cancer screenings were covered by the ACA. The ACA also stipulated that women can see OB-GYNs for primary care. This is the same as what many women do for their reproductive and preventive health care. Insurers cannot charge more for women’s care. This was a practice that existed before the ACA protections, known as “gender ratings.” The law also requires that employers with 50 or more employees provide breaks and private rooms to breastfeeding women. While this is still a difficult task for many Mississippi communities, the federal law supports public health support. Breastfeeding support is covered by insurance. This includes lactation counseling and breast pumping. These are two barriers that have been preventing women from breastfeeding in the past, particularly in low-income communities. Pre-existing conditions are more common in women than they are in men. This could make them unable to receive coverage under the ACA. They are less likely to have a family caregiver, make more money and use more healthcare. This can add to the burden of health care costs. Cost concerns are another reason women are more likely to cancel their insurance. The law expands the role of state governments in ensuring health insurance access. It gives states flexibility to expand Medicaid eligibility to those in poverty to help address affordability gaps. Prior to the law, those who didn’t have enough income to purchase health insurance were not eligible for Medicaid eligibility. In 39 states, individuals who earn up to 138% of federal poverty, or approximately $17,000 per person, are now eligible. Some other states, such as Georgia, have used federal waivers in order to benefit from parts of Medicaid expansion. Georgia extended Medicaid eligibility for postpartum mothers from two to six month coverage after the birth, a decision that was supported by maternal health specialists. While expanding Medicaid coverage to include women before they become pregnant has been shown to improve infant and maternal outcomes, advocates argue that extending coverage beyond 60 days after birth can help improve outcomes. Studies show that states that expanded postpartum Medicaid eligibility resulted in a decrease in the number of women who die during or after childbirth. Mississippi is among 10 states that have not expanded Medicaid eligibility or taken advantage of a partial waiver to make Medicaid more affordable for low-income people. Mississippi has not expanded eligibility to women who are part-partum, as they do not appreciate high infant and maternal mortality rates. Nearly 40% of Mississippi women who are born with complications after birth occur within six weeks. Medicaid is cut off for these women. Mississippi Medicaid temporarily extended postpartum eligibility during the COVID-19 crisis. States cannot remove women who were covered by Medicaid while pregnant as a condition for federal COVID-19 relief dollars. The benefit is currently in effect until late January. However, it may be extended if federal officials extend the timeline for a federal public health emergency. Linda Dixon, a health policy attorney at Mississippi Center for Justice, said that you cannot talk about the ACA without addressing what was left behind. Around 150,000 Mississippians are in the coverage gap. They don’t qualify to receive Medicaid, as it was not expanded to include non-disabled people living in poverty. However, they earn too little to be eligible for tax credits from the marketplace to pay for insurance. Because the marketplace was designed to expand Medicaid, it is not eligible for incomes below 100% of poverty. The idea behind the marketplace was to help people above the federal poverty level and Medicaid to capture those below it at the time of its creation. People living in poverty in the 12 states that did not expand Medicaid were unable to get either and were left in that gap of uninsured and unprotected. These states have the highest rates of uninsured and the most hospital closures. The gap is likely to widen due to the imminent decision to repeal the ACA. Experts estimate that more than 21,000,000 people nationwide and at least 100,000 in Mississippi would lose their insurance if this law is repealed. This would increase the gap and reverse the insurance gains of the past decade. Dixon asked rhetorically “There are so many factors to consider that Americans and Mississippians had access to for ten years. What does that look like moving ahead, how will that affect Mississippians?” Dixon was echoing the sentiments of health policy experts from across the state, who believe undoing the gains made by the ACA could lead to more unknowns for the state as COVID-19 shakes the health care system. “Mississippi Families deserve better than this.” The federal marketplace is open for enrollment through December 15, 2020 to provide coverage for 2021. For more information visit healthcare.gov or to get assistance from certified community counselors.