The Patient Protection and Affordable Care Act (ACA) created important opportunities for unand underinsured people to gain affordable health coverage. This has proven especially vital for people who are approaching Medicare eligibility. Those between ages 55 and 64 made up around 26% of Marketplace enrollees in 2015, nearly 3.3 million people.1 People with disabilities also have coverage through the ACA, including those who are in the two-year waiting period for Medicare coverage and people who are still working through the formal disability process. The ages and health statuses of many of these individuals means that without the ACA’s robust consumer protections—such as community rating and pre-existing condition protections—they might be unable to access affordable, or in some cases any, comprehensive health coverage.

States are permitted to make limited changes to some ACA functions within the state through 1332 waivers, though these changes must meet procedural and substantive standards and cannot upend the community rating and pre-existing condition protections. Before being granted a waiver, the state must demonstrate how the waiver will provide for coverage that is “at least as comprehensive” and “at least as affordable” and covering “at least a comparable number of its residents” without increasing the federal deficit.