The Past, Present, and Future of the Affordable Care Act

The Affordable Care Act (ACA), also known as Obamacare, was one of the most significant pieces of legislation created in US history. Passed just over a decade ago in President Barack Obama’s tenure, the act fundamentally changed the health insurance landscape of America and expanded access to care to millions. In transforming America’s approach to health insurance, the act has drawn both impassioned supporters and biting critics with each side engaged in constant legislative and judicial battles on behalf of the ACA. At a time when COVID-19 has made having health coverage more important than ever and as a new president takes office, it’s a good time to take a closer look at this groundbreaking piece of legislation. By analyzing the law through the lens of both opponents and allies, we can gain a better sense of what health insurance, and subsequently, American public health, will look like in the coming decade.

Those sympathetic to the ACA argue the act’s subsidized exchanges that expanded care to more uninsured Americans, pre-existing conditions provision, and baseline coverage requirements have made it indispensable to the public health of the country. Since the law was passed in 2010, over 15 million people who did not have health insurance gained it as a result of the plan’s subsidized insurance exchanges and pre-existing conditions coverage (Tolbert & Orgera, 2020). At a basic level, more Americans on health insurance is good for public health as it has been shown those who lack it are at a greater risk of mortality (Woolhandler & Himmelstein, 2017). Researchers have also noted that those who gained insurance because of the ACA were subsequently more likely to use primary care services of their plan, which would likely help doctors better catch risk factors in their patients and prevent diseases down the line (Pang et al., 2020 ;The Importance of Primary Care Physicians, 2014). The increased availability of health insurance to working class Americans through subsidized exchanges has been especially critical in recent times, as many have lost health insurance coverage as a result of a pandemic-related lay off (Agarwal & Sommers, 2020). Before the act, many of these Americans would struggle to regain similar insurance plans, as they likely wouldn’t have qualified for a government assistance program like Medicaid, but because of Medicaid Expansion under the ACA, many of these people have been able to transition to other comparable plans (Agarwal & Sommers, 2020). The law has also made health insurance overall more inclusive, both in terms of people who can access it as well as what it is required to cover. After going into effect, the law made it illegal for insurance companies to deny coverage for patients with pre-existing conditions (Rambur, 2020), a provision that has remained almost universally popular, despite Americans being fairly divided on the act overall (Hamel et al., 2020). During the current pandemic, this provision deserves a special focus as well, as many consider COVID-19 to be a pre-existing condition. In cases where COVID-19 survivors struggle with lingering health effects (known as “long haulers”), they could be newly placed into a patient category protected by the ACA (Appleby, 2020). Beyond COVID-19 patients, though, an estimated 27% of all Americans, aged 18-64, have a pre-existing condition, demonstrating just how many people are affected by this one specific provision alone (Claxton et al., 2019). Additionally, of those who have health insurance, Obamacare requires all plans to cover many basic, fundamental services including primary care, mental health services, emergency care, and maternity care, among others, lifting a financial burden off many patients (Tolbert, 2019). The transformative nature of the Affordable Care Act in increasing coverage to millions more Americans, guaranteeing insurance to those with pre-existing conditions, and requiring basic services to be covered in all plans are some of the many reasons why proponents strongly defend it.

Critics of the ACA cite the financial impact the law has had on middle class families and the increased role of government and healthcare to argue the law should either be partially changed or completely repealed. For the majority of people who utilize the insurance changes Obamacare created, their plans are often cheaper than before because the ACA subsidizes those earning below a threshold level (Luhby, 2016). However, for many middle class families making just above the income threshold, their plans receive no government subsidy and can often be substantially more expensive than before the ACA was put into place (Luhby, 2016). This occurrence is exacerbated by the “subsidy cliff” where even if an individual makes just slightly more than the threshold for receiving subsidies, they don’t receive any government assistance at all. Although the financial impact of the ACA varies by geographic location, a 40 year old earning 50,000 would pay over 10% of their income to health insurance in 21% of counties (Fehr et al., 2020), which is, understandably, an enormous financial strain. Both political parties have drafted plans to address high premiums and deductibles among middle class individuals, but differing approaches and political gridlock has left the country without a sweeping solution (Fehr et al., 202).

In addition to financial grievances toward the ACA, many oppose it from an ideological standpoint. 78% of conservatives support overturning the act completely, with the common rationale being that the government should not play an expanded role in healthcare (Hamel et al., 2020; Dalen et al., 2015). Conservatives also find the individual mandate, requiring all Americans to buy insurance, as particularly unpalatable, and removed the requirement through an act of Congress in the past year (Dalen et al., 2015; Kliff, 2020). Recently, politicians have taken polarizing positions on Obamacare from both ends of the political spectrum. The previous president and leader of the Republican Party, Donald Trump, routinely attacked the ACA and argued in favor of “repealing and replacing” it, although had never revealed a comprehensive replacement plan (Olorunnipa, 2020). From the Democratic side, former presidential candidate Bernie Sanders argued in favor of a Medicare For All plan that would cover all Americans under government insurance and hence make the ACA obsolete (Medicare for All, n.d.) In contrast to both, President Joe Biden has stated he would like to build off Obamacare by creating a public option (“like Medicare”) that could compete with private insurance, and lower premiums for middle class families, among other proposals (Health Care, 2020).

In looking toward the future of the Affordable Care Act and health insurance in the United States, it’s worth paying attention to the current political, legislative, and judicial dynamic that may dictate the nation’s course. Many postulate President Joe Biden will begin rebuilding areas of the ACA that were previously dismantled by Donald Trump through executive actions and regulation changes (Keith, 2020). However, much of the larger changes President Biden and Democrats would hope to enact into law, such as the creation of a public option, would likely require an act of Congress and, most likely, a Senate majority, which Democrats narrowly gained through wins in two Senate runoff elections in Georgia (Hellman, 2020; Segers et al., 2021). While this political process plays out, another debate is occuring in the Supreme Court in the case of California v Texas, where the Court will look at the constitutionality of the ACA (Musemeci, 2020). Many experts don’t anticipate the court striking down the Affordable Care Act entirely (Hagen, 2020), as the justices have seemed willing to rule against the law’s individual mandate while not rebuking the act as a whole. The recent appointment of Justice Amy Coney Barrett, and the subsequent shift in judicial dynamic, however, makes predicting a ruling more difficult (de Vogue, 2020). Finally, it remains unseen how the political battle of health insurance in the United States will play out in terms of if Republicans will continue to follow Donald Trump’s lead in trying to dismantle the ACA without a viable alternative, draft a new replacement plan, or attempt to work within Obamacare’s framework. From the other side of the aisle, Democrats lack a unified front on whether to rebuild the current ACA policy or create a more expansive plan entirely, and it doesn’t appear a resolution will come anytime soon.

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