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United States Health Insurance

Affordable Care Act

The Affordable Care Act includes the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. Sometimes known as "Obamacare," the Act aimed to expand Medicaid coverage and improve Medicaid and the Children's Health Insurance Program.
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Following its passage in 2010, the ACA continued to add provisions each year. Here, some of the law's original plans and policies are summarized, without specific detail on the year of implementation.

  • Establish state-based American Health Benefit Exchanges for individuals to compare and purchase insurance.

    • Includes premium and cost-sharing credits to low-income participants​

    • Some states use HealthCare.gov, a federal site, while others have their own markets

  • Expand Medicaid eligibility to 133% of federal poverty level

  • Individual Mandate required U.S. Citizens and residents to have health coverage or pay a tax penalty, with some exceptions depending on financial circumstance, religion, incarceration, and length of uninsured period, among other factors.

    • Repealed later​

  • Offered premium credits to individuals and families with incomes between 100% and 400% of the Federal poverty level through the governmental Exchanges

  • Maintained the Hyde Amendment, which prohibits the use of federal funding (and by extension, premium and cost-sharing subsidies) to cover abortions, with the exception of cases that save the life of the woman or arise from rape or incest

  • Reinsurance program- grants 80% reimbursement to employers who pay for retiree (over 55, ineligible for Medicare) claims between $15,000 and $90,000

  • Impose new fees on pharmaceutical and health insurance sectors

  • Create state-based Small Business Health Options Program Exchanges

  • Established an essential health benefits package (set of services) in order for plans to qualify

    • Mental health and substance abuse services were included, and private providers must have the same benefits for mental and physical health​

  • Provided grants to states that review and approve premium increases

  • Allow children up to age 26 to stay on their parents' insurance

  • Create a variety of funds, centers, and administrations to research and manage initiatives related to healthcare and medical innovation

  • Increase Medicaid drug rebate percentage

  • Reduce waste, fraud, and abuse through provider screening

  • Establish the Patient-Centered Outcomes Research Institute to help with effectiveness

  • Incentivize primary care physicians to join Medicare

  • Provide grants to providers in underserved areas

  • Increase healthcare workforce with scholarships and loans as incentives

  • Require non-profit hospitals to assess and address community health needs every three years

  • US Department of Health and Human Services must establish a National Quality Strategy

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Mandatory Benefits for Individual Marketplace Plans

The ACA requires marketplace plans to cover 10 areas: (copied directly from HealthCare.gov)

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)

  • Emergency services

  • Hospitalization (like surgery and overnight stays)

  • Pregnancy, maternity, and newborn care (both before and after birth)

  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)

  • Prescription drugs

  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)

  • Laboratory services

  • Preventive and wellness services and chronic disease management

  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

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Individual Marketplace plans also need to cover in-network birth control and contraceptive counseling.

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Impact of the Affordable Care Act

General Impact

  • 20 million Americans gained coverage

  • Between 2010 to 2019, the percentage of uninsured people decreased from 20% to 9%

  • Increased coverage, especially among the poor (13 million increase in Medicaid enrollment)

  • Improved quality and efficiency

  • Strengthened public health, primary care, and preventive care

  • Major improvements for patients with pre-existing conditions

  • Reduce disparities for people of color

  • Removal of the lifetime cap allowed for longer coverage

  • Recently, researchers have agreed the act improved health and reduced mortality

  • Increased profits for insurance companies (after a steep learning curve)

  • Failed to meaningfully reduce costs on a wide scale, especially for the middle class

  • Allowed high deductibles that currently place heavy burdens on patients​

  • Has helped keep hospitals in business, as their patients are now insured and are able to pay the hospital

  • Increased supply of health professionals

  • Increased availability of preventative care

  • Didn't make health care more affordable overall- the result is that in America, people still avoid medical care due to cost. In other countries, this hasn't been an issue during the pandemic. 

  • Some states are using their marketplaces to provide special insurance enrollment

COVID-19 Impact

Court House

Challenges and Changes to the Affordable Care Act

The Individual Mandate

In 2012, a challenge over the individual mandate, which imposed a fine on uninsured Americans, when to the Supreme Court. Chief Justice John Roberts, along with a narrow majority, upheld the mandate.

In 2017, Republicans in Congress passed a tax bill eliminating the mandate, sparking fears of premium increases due to a lower number of consumers. However, insurance coverage data seems to show that the mandate had a limited effect on enrollment, and the Affordable Care Act remains effective without it. 

State Opposition

Many Republican governors refused to follow the ACA, failing to set up marketplaces, advertise the new insurance options, or sign up for subsidies. They also didn't expand Medicaid eligibility, as the Supreme Court ruled it optional. Currently, people in states like Texas and Florida remain uninsured despite being eligible under the ACA because state officials are opposed to increased Medicaid coverage.

Trump Administration Challenges

Having campaigned on promises of repealing the Affordable Care Act, President Trump's administration has enacted various limits on the Act.

  • Reduce funding for Exchange advertisements and enrollment programs: In 2017, the Department of Health and Human Services reduced the advertising budget for the program from $100 million to $10 million. They also cut $36 million from grants previously given to organizations that helped with enrollment. They argued that public awareness of the program was not an issue that required the funds. 

  • Reduce insurance company subsidies: Under the original ACA, insurance companies that offered their plans on the government exchanges were subsidized in order to reduce risk and encourage competition by increasing options. The Trump Administration and congressional Republicans opted to cut such subsidies. 

  • Easing quality requirements: In order to reduce costs, the Administration loosened requirements on covering essential benefits, keeping costs low for patients with pre-existing conditions, and prohibiting spending caps. 

  • Impact on noncitizens: The Department of Homeland Security issued a rule saying enrollment in Medicaid could negatively impact immigrants applying for changes in residency status or extensions on their stays. 

  • Supreme Court Repeal: In November, the Supreme Court will hear a case regarding the potential repeal of the Affordable Care Act. 

“Find out What Marketplace Health Insurance Plans Cover.” HealthCare.gov, www.healthcare.gov/coverage/what-marketplace-plans-cover/.

Goodnough, Abby, et al. “Obamacare Turns 10. Here's a Look at What Works and Doesn't.” The New York Times, The New York Times, 23 Mar. 2020,

www.nytimes.com/2020/03/23/health/obamacare-aca-coverage-cost-history.html.

Goodnough, Abby, and Robert Pear. “Trump Administration Sharply Cuts Spending on Health Law Enrollment.” The New York Times, The New York Times, 31

Aug. 2017, www.nytimes.com/2017/08/31/health/affordable-care-act-trump-spending.html.

Kliff, Sarah. “Republicans Killed the Obamacare Mandate. New Data Shows It Didn't Really Matter.” The New York Times, The New York Times, 18 Sept. 2020,

www.nytimes.com/2020/09/18/upshot/obamacare-mandate-republicans.html.

Pear, Robert. “Without the Insurance Mandate, Health Care's Future May Be in Doubt.” The New York Times, The New York Times, 19 Dec. 2017,

www.nytimes.com/2017/12/18/us/politics/tax-cut-obamacare-individual-mandate-repeal.html.

Shapiro, Ari, and Julie Rovner. “10 Years Of The Affordable Care Act.” NPR, NPR, 23 Mar. 2020, www.npr.org/2020/03/23/820293431/10-years-of-the-affordable-

care-act.

“Summary of the Affordable Care Act.” KFF, 25 Apr. 2013, www.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/.

Thompson, Frank J. “Six Ways Trump Has Sabotaged the Affordable Care Act.” Brookings, Brookings, 9 Oct. 2020,

www.brookings.edu/blog/fixgov/2020/10/09/six-ways-trump-has-sabotaged-the-affordable-care-act/.

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