The 2010 Patient Protection and Affordable Care Act (ACA) has been the subject of much political, legal, and social discussion and debate. The act, also known as Obamacare, expanded Medicaid to low-income adults under 65 and created state-level health insurance marketplaces with subsidies for many Americans and has so far led to over 21 million people in 40 states, Washington D.C., and other territories gaining health coverage. Enrolled individuals can access Essential Health Benefits, including preventive and rehabilitative care, prescription drugs, wellness visits and contraceptives, mental health and substance use treatment, and many others.1,2
As of early 2022, an estimated 35 million people were enrolled in Medicaid expansion, Marketplace coverage, and the Basic Health Program in participating states, bringing uninsured rates to record lows of 8.8% for the full population. This growth in coverage is due in part to Oklahoma and Missouri’s expansion of Medicaid in 2021, and a historic 14.5 million people signing up for health care coverage through the Marketplace Open Enrollment Period from 2021-2022.1
Among the major advancements put forward through the ACA are protections for more than 133 million people with pre-existing conditions, including pregnancy, cancer, asthma or diabetes, from being denied coverage for their condition. It extended protections for Americans with disabilities by eliminating lifetime dollar caps on essential health benefits and stipulating that people cannot be discriminated against by health insurance plans on the basis of medical history. The ACA has improved coverage for family and women’s health, covering birth control and counseling, breast and cervical cancer screenings, prenatal care, interpersonal violence screening and counseling, and HIV screening and STI counseling. Expanding Medicaid and the Children’s Health Insurance Plan (CHIP) for pregnant and postpartum individuals to a full year after pregnancy is another example of a recent effort to address disparities.2
Mental health and substance use support and health of underserved minorities, such as LGBTQI+ individuals and people of color, are also areas of high priority in ACA legislation, with new offices and grants dedicated to expanding coverage and support for these communities. For example, approximately 7 million of the people who have gained coverage so far under Obamacare since 2010 are Black or Latinx.2
The law has been contentious from the start, and some aspects of it have been repealed. Obamacare has faced many legal challenges so far. In 2012, a landmark 2012 Supreme Court decision scaled back Medicaid expansion from a nationwide mandate to a state option.3 In 2017, the so-called “individual mandate” — a provision that required individuals to purchase minimum essential coverage or face a tax penalty unless they were eligible for an exemption — was effectively eliminated.4 Technically, the mandate continues to exist, per the Supreme Court’s 2021 ruling in Texas v. United States, but without the penalty, though some states have implemented their own.3
Texas v. United States was one of numerous other cases arguing that the ACA should be overturned, on the basis of the constitutionality of the individual mandate provision.3 As of late 2020, approximately three-quarters of Republicans voiced wanting to overturn the entire ACA, while 89% of Democrats did not. Notably, there are some elements of the ACA that are popular across partisan lines, such as protections for pre-existing conditions — supported by 66% of Republicans and 91% of Democrats.5
There are undeniable benefits to expanded and subsidized health insurance, with studies highlighting reductions in health disparities and opioid-associated hospitalizations in states with Medicaid expansion.6,7 Still, there remains much work to shift the health care system away from payment for volume toward payment for value, an aim often discussed in bipartisan legislation but never fully delivered upon.8 This will be impossible without major improvements in quality measurement and health data collection. In order to increase payment for value, more resources must be devoted to determining best practices for measuring quality and incorporating quality metrics into health legislation in a meaningful way.8 Though the ACA, also known as Obamacare, is not a complete solution, it has so far led to many benefits, especially for vulnerable populations.
References
1. Assistant Secretary for Public Affairs (ASPA). New reports show record 35 million people enrolled in coverage related to the Affordable Care Act, with historic 21 million people enrolled in Medicaid expansion coverage. US Department of Health and Human Services. Published April 29, 2022. https://www.hhs.gov/about/news/2022/04/29/new-reports-show-record-35-million-people-enrolled-in-coverage-related-to-the-affordable-care-act.html
2. Assistant Secretary for Public Affairs (ASPA). Fact sheet: Celebrating the Affordable Care Act. US Department of Health and Human Services. Published March 18, 2022. Accessed May 29, 2023. https://www.hhs.gov/about/news/2022/03/18/fact-sheet-celebrating-affordable-care-act.html
3. McIntyre A, Song Z. The US Affordable Care Act: Reflections and directions at the close of a decade. PLoS Med. 2019 Feb 26;16(2):e1002752. doi: 10.1371/journal.pmed.1002752.
4. Fiedler M. The ACA’s individual mandate in retrospect: What did it do, and where do we go from here?: A review of recent research on the insurance coverage effects of the Affordable Care Act’s individual mandate. Health Aff (Millwood). 2020;39(3):429-435. doi:10.1377/hlthaff.2019.01433
5. Kirzinger A, Lopes L, Kearney A, Brodie M. KFF health tracking poll – October 2020: The future of the ACA and Biden’s advantage on health care. KFF. Published October 16, 2020. Accessed May 29, 2023. https://www.kff.org/health-reform/report/kff-health-tracking-poll-october-2020/
6. Wen H, Soni A, Hollingsworth A, et al. Association between Medicaid expansion and rates of opioid-related hospital use. JAMA Intern Med. 2020;180(5):753-759. doi:10.1001/jamainternmed.2020.0473
7. Patel MR, Tipirneni R, Kieffer EC, et al. Examination of changes in health status among Michigan Medicaid expansion enrollees From 2016 to 2017. JAMA Netw Open. 2020;3(7):e208776. doi:10.1001/jamanetworkopen.2020.8776
8. Buntin MB. The affordable care act at 10 years. JAMA Health Forum. 2020;1(7):e200896. doi:10.1001/jamahealthforum.2020.0896
