Marking 10 Years Of Obamacare In The Shadow Of Coronavirus

On March 23, 2010, the Affordable Care Act (ACA) was passed, introducing sweeping healthcare reform designed to make affordable health coverage available to more Americans, expand Medicaid to cover all adults with income below 138% of the federal poverty level, and support innovative efforts to reduce healthcare costs while also improving quality of care.

Most of us can remember the ACA’s bumpy takeoff — crashing web site, hit-or-miss enrollment efforts, unforeseen cost increases — and political posturing that gave rise to the Act’s nickname, Obamacare, which was sometimes uttered with pride and sometimes with scorn. So began the debate that still rages today: is the ACA worth improving and building upon, or is it so flawed that it should scrapped completely?

Consider this remarkable fact: 20 million more Americans have health insurance today because of the ACA.  Medicaid expansions of course cover low-income Americans. But what most Americans don’t understand is that the exchanges also predominantly cover low-income people, most of whom work. Recent data shows that 75 percent of Americans purchasing insurance on exchanges qualify for federal subsidies (premium tax credits) that lower costs for households with incomes between 100% and 400% of the federal poverty level. Black Americans, children and small business owners have particularly benefited.  

The cost of caring for uninsured Americans, whose health needs are often complex, chronic, and exacerbated by social determinants, has long crippled our healthcare system. The ACA is proving instrumental to a solution: 10 years in, and 20 million more Americans have access to basic primary care, which often prevents minor problems from becoming serious —and expensive —conditions. More Americans can maintain their own health to better care for their children and aging parents, and actively engage in their communities. For all the complexity of healthcare, this is simple: covering low-income Americans make for healthier communities, and healthy communities make for a healthier, stronger country.  

Conversely, repeal of the law without a functional replacement would strip care from those who need it most.  And particularly the critical provision prohibiting insurance companies from charging premiums based on health status. This is why Congress was not successful in repealing the ACA previously. And as Coronavirus has raised public understanding of the importance of primary care and insurance coverage generally, repeal of the ACA has become an impossibility.  Building on existing coverage, and the framework that no one can be denied care based on a pre-existing condition, is now the only feasible option for members of both parties.

Approximately 30 million Americans remain uninsured today. Of them, 13 million live in states with Super Tuesday primaries, and more than 75 percent are eligible for help affording insurance coverage. Based on analysis by Avalere Health, reforms targeting the affordability and availability of current insurance options could reduce this number of uninsured without fundamental changes to existing programs. In other words, adding new programs, as some Democratic candidates have proposed, will not make a difference if they’re not affordable and accessible. But higher enrollment of Americans eligible for Medicaid, CHIP or an ACA exchange market subsidy, could.

A key feature of the original ACA was an individual mandate penalty to encourage enrollment in comprehensive coverage and effectively diversify the health status of the risk pool. In 2017, the Tax Cuts and Jobs Act reduced the penalty to $0 as of January 2019, effectively eliminating the mandate. This removed one of the ACA’s mechanisms to protect the exchange markets against anti-selection, and also increased the number of uninsured people.  Even without the mandate, however, the ACA marketplaces remained relatively profitable and stable for most insurance companies offering them.

And despite the political overhang of ongoing repeal efforts, the ACA is fulfilling much of its purpose. Because of Medicaid expansion, 12 million Americans have health insurance coverage. Several states that chose not to expand Medicaid have yet to implement alternative plans that sufficiently fulfill the fundamental purpose of Medicaid: to protect the health of the most vulnerable Americans. For some of these states, the logic of the ACA’s Medicaid expansion is proving politically irresistible: for the second year straight, the ACA exchanges show improvement: 20 more insurers are joining the federal exchanges in 2020, and the average premium for the benchmark plan will drop by 4% in the 38 states that use the federal ACA exchanges. 

All governors should jump on the expansion of their Medicaid programs – especially this year when healthcare is the number one issue for voters, and the Coronavirus has heightened the urgency of a strong public health infrastructure.  Full expansion of Medicaid under the ACA would go a long way towards achieve universal coverage for low-income Americans.

Our healthcare system has a way to go to fulfill the original promise of the ACA: to make affordable, high quality health care available to all Americans. There is still much to be done to improve cost efficiencies and health outcomes. Increasingly, it appears that continuing to improve what the ACA began, rather than scrapping it altogether, is the best route forward. We will not know the legal fate of the ACA until the courts rule on severability, which will almost certainly wait until after the presidential election in November. Until then, we’ve got to keep working to improve not just the system, but the health of all Americans, singly and together.