Looking at the ACA a decade later

The U.S. health care system is now a little more than a decade into the era of the Patient Protection and Affordable Care Act. Passed in late March 2010, in the wake of a devastating financial crisis that caused millions to lose employer-sponsored coverage, some measures of the law went in place immediately while others took years to come together. In all, the law has effectively altered the landscape for care providers, insurers, patients and more over the last decade.

Perhaps the most notable aspect of the law – and this will certainly be the case from the average American's perspective – is that it has greatly reduced the number of uninsured people nationwide. According to The New York Times, when the law was first passed, more than 22% of adults under the age of 65 (at which point they would be eligible for Medicare) were uninsured. Today, that number has been reduced by about half. Altogether, the law – and the changes it ushered in – led to about 20 million more Americans getting coverage.

Part of that has also come as dozens of states took the federal government up on offers of support when it comes to broadening Medicaid eligibility, the report said. Today, only 14 states have not expanded their own programs, and nationwide, about 13 million people are covered as a result of Medicaid expansion.

The ACA has fundamentally altered the American health care landscape.

Other successful aspects of the law
In addition to simply getting more people covered, the law also established some other benchmarks for minimum standards of coverage overall, according to the National Law Review. These include making sure people with pre-existing medical conditions could not be denied insurance, as well as requiring insurers to more broadly cover certain things associated with health care, including covering costs for mental health care and prescription drugs, among other things.

The law also created a raft of federal subsidies to help people afford coverage who otherwise couldn't meet their premiums. There were also rules about how much the average premium could rise from one year to the next, how much of collected premiums could go toward insurers' overhead costs and profit margins, and so on. Many of these have combined to create conditions that led to more affordable and better care for most Americans.

Challenges come and go
In the decade since the ACA first passed, there have been numerous challenges to various aspects of its impact. Speaking with National Public Radio, Kaiser Health News chief Washington correspondent Julie Rovner noted that some of the fundamentals of the law have been challenged unsuccessfully in the Supreme Court, while legislative efforts to remove some of the teeth of the law have taken place more recently.

Front and center on both sides of that coin is the individual mandate, a key component in the law that was intended to simultaneously get more people insured and also widen the risk pool for insurers as a means of keeping premiums lower. That aspect of the law was first challenged – unsuccessfully – in 2012 but was later stripped out as part of a tax reform bill in 2018. 

However, mandatory Medicaid expansion was actually struck down by the Supreme Court, which is why more than a dozen states still haven't acted on that. Nonetheless, efforts to “repeal and replace” the ACA have not come to fruition – at least not yet.

What does the future hold?
Of course, the ACA has also fundamentally changed the tenor of the national debate around health insurance as a whole, and it is broadly understood that very little about the law is fully set in stone, according to Yahoo Finance. At some point after the upcoming elections, the Supreme Court is expected to issue a ruling on a challenge to the constitutionality of the ACA. Given the makeup of the Court at this point, it seems possible – even likely – that it could agree with a 2018 Texas ruling that found the individual mandate invalid (due to a lack of penalty) and, thus, the whole law as well.

However, experts believe such a ruling would create a potentially chaotic scenario, especially at a time when millions will be in a situation many faced when the ACA was first passed: Joblessness – and thus a lack of insurance – brought on by a near-unprecedented economic downturn. That could mean those people not only don't have employer-sponsored coverage, they also won't receive subsidies to help them pay for coverage and, depending on where they live, they also may not even have exchanges through which they can purchase individual health insurance.

Much remains up in the air about the state of the ACA, but what is known is insurers (who saw millions of Americans join the rolls of the insured) and consumers (who may have received coverage for the first time in their lives) have seen a mutual benefit in certain aspects of the law.