A decade after it was signed into law, the Affordable Care Act (ACA) has provided millions of Americans with access to health insurance, and still remains a topic at the center of political discourse. Aekkarak Thongjiew / EyeEm / Getty Images
  • The Affordable Care Act (ACA), also known as “Obamacare,” was signed into law in 2010.
  • The legislation was designed to address several perceived gaps in America’s existing health insurance system.
  • Despite providing health insurance to millions of Americans, the ACA has remained a hotly debated topic, with many people still unclear about what it is, how it works, and how it can be expanded or improved.

On March 23, 2010, the Affordable Care Act (ACA) was signed into law, the most significant national healthcare reform in the United States in about half a century.

Though its goal is to provide all U.S. citizens with health insurance, the ACA has hit some stumbling blocks over the decade since it was first signed into law by President Barack Obama.

Used as a political punching bag, “Obamacare” has faced multiple threats of being repealed by Republican politicians, many of them happening over the past 3 years during the Trump administration.

Today, its fate is once again imperiled by the fight to fill an open Supreme Court seat following the death of Justice Ruth Bader Ginsburg, compounded by a contentious presidential election.

On top of all this, the COVID-19 pandemic is putting unprecedented strain on our nation’s healthcare system.

Once again, healthcare is at the center of American politics.

Often lost sight of in all of the political debates is the fact that the ACA has made healthcare available to millions more people. Because of the ACA, affordable coverage is accessible to Americans with lower incomes, people who are unemployed, and those living with preexisting conditions, like chronic illnesses.

While the ACA has become a key part of healthcare for millions of Americans, it has remained at the center of political discourse.

Yet a lot of people are still confused about what it is, how it works, and what possibilities are out there to expand and improve it.

Here’s an overview of where the ACA stands in 2020, a decade after its introduction, and what may happen to healthcare for millions of Americans if it’s soon repealed.

What is ‘Obamacare’ and how does it work?

A 2010 article in the journal Health Affairs calls the ACA “the most important health care legislation since the 1965 law that created Medicare and Medicaid.”

Despite this historic significance, many people don’t really know what this health legislation even is.

The ACA essentially is the name for the overall health reform legislation signed into law in 2010.

It was enacted in two parts: the Patient Protection and Affordable Care Act, signed into law on March 23, 2010, and the Health Care and Education Reconciliation Act, signed days later on March 30.

To expand coverage to as many Americans as possible, the legislation was designed to address several perceived gaps in America’s existing health insurance system.

One was to provide tax credits to lower healthcare costs for households with incomes somewhere between 100 percent and 400 percent of the federal poverty line.

The second was to expand Medicaid coverage to U.S. adults with incomes 138 percent below the poverty level.

One caveat of this is that not all states have expanded Medicaid. Right now, 38 states and the District of Columbia have adopted Medicaid expansion, the Kaiser Family Foundation (KFF) reports.

This expansion of services to people and families with low income levels has been shown to be a great boon to overall public health. A recent study found that Medicaid expansion led to earlier cancer detection rates.

Additionally, the ACA put in place several healthcare delivery system reforms to help lower costs overall.

How do you get “Obamacare” coverage? Every year there is an open enrollment period for coverage that begins January 1 of the upcoming new year.

To apply for a health insurance program, you need to go through the Health Insurance Marketplace, where you are able to see what plans are available in your state. Some states run their own marketplaces, once known as “exchanges.”

For 2021 coverage, the enrollment period runs from November 1 to December 15 this year.

If you miss the deadline, certain situations might allow you to qualify for a “special enrollment” period. For instance, maybe you had a child or lost your job.

People who qualify for Medicaid or the Children’s Health Insurance Program (CHIP) can apply for a plan at any time.

Once you’re on your plan, it will run for the rest of the year. You can then renew your plan during the next enrollment period the following fall.

A report from earlier this year showed that 8.3 million people either signed up for or renewed health insurance via the ACA for 2020 coverage.

Why is the ACA misunderstood?

Oftentimes, how “Obamacare” is discussed and framed has led to misunderstanding of the ACA.

The legislation is a series of provisions, opening up a marketplace of different tiered plans from which citizens can choose. It’s not a health insurance plan in and of itself, the way some anti-ACA-leaning media outlets tend to depict it.

When asked why there tends to be so much confusion over what exactly “Obamacare” is, John McDonough, DrPH, MPA, a professor of public health practice in the Department of Health Policy & Management at the Harvard T.H. Chan School of Public Health and director of executive and continuing professional education, said it’s because American healthcare is confusing to begin with.

“Ask Americans to explain Medicare and or Medicaid, and you will observe at least as much befuddlement as with the ACA. Our U.S. healthcare system is the most complicated and impenetrable to understand and make sense of on the planet,” McDonough told Healthline.

He should know. McDonough was there at the beginning.

He worked on the development and passage of the ACA in the role of a senior advisor on national health reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions.

“In the early days around 2010, when people would complain to me that they didn’t understand the ACA, I would ask them — politely — how well they understand the U.S. health system in general,” he said.

“100 percent would indicate that they didn’t understand that at all either. So if you don’t understand the core system, it shouldn’t be surprising that understanding the reform of that system is also hard to grasp.”

McDonough explained that partisan politics and inaccurate media framing of the law added to immense confusion, but added that he doesn’t “see those as the prime perpetrators.”

Leighton Ku, PhD, MPH, professor and director of the Center for Health Policy Research at the Milken Institute School of Public Health at George Washington University, told Healthline that the ACA has become a “litmus test” for “how you feel about Democrats and Republican, liberals and conservatives” rather than a method for enabling access to healthcare.

He said the country is unfortunately split somewhat “down the middle” between those who approve and disapprove of the ACA.

“The polls tend to say when you bring up specific issues under the Affordable Care Act, things like preexisting conditions, Medicaid expansion, by and large, a pretty substantial majority of Americans support all those things,” Ku said.

“But when it’s all packaged together into ‘Obamacare,’ suddenly a lot of people see red when they see that banner being waved.”

How the ACA has improved healthcare access in the United States

Anya Rader Wallack, PhD, associate director of the Center for Evidence Synthesis in Health (CESH) and a professor of the practice in the Department of Health Services, Policy and Practice within Brown University’s School of Public Health, told Healthline the controversy surrounding “Obamacare” is ironic to her, given that it is “not one of the more radical proposals” for health reform.

Progressive critics of the ACA say it doesn’t go far enough in guaranteeing healthcare for all citizens. It falls short of the vision of a single-payer system like Medicare for All, which would mean a sole public health system would exist, like those in Canada and some countries in Europe.

While the ACA might not fall in that category of reform, Wallack said that it did “set a new bar in terms of fairness across the (healthcare) market.”

While she said total 50-statewide Medicaid expansion — as was originally intended — would have been significant, the fact that the majority of states have now chosen that option is, in her view, “the most radical part of the law.”

Wallack said this means a single parent or a pregnant woman or a child, for instance, has that added level of security in knowing they can get covered. She said states that enabled this resulted in “the most significant bump” in coverage, like what was witnessed in her own state of Rhode Island.

She added that it was also “a big deal” that the tax credits given to people whose income is at up to 400 percent of the poverty line to buy coverage through the marketplace was also a game changer.

Beyond this, the law’s provision that a young person can stay on their parents’ insurance until the age of 26 also helped level the playing field. This is especially true for young people just out of school who might not have employment or might be experiencing poverty.

From his vantage point, McDonough said that, until recent attacks on the ACA from the Trump administration and the impact on healthcare and the economy from COVID-19, “the rate of un-insurance in the U.S. had dropped to its lowest level since we started counting in the 1960s, between 8 to 9 percent overall.”

He added, “The highest level of drops were among the lower income categories with the greatest unmet needs. Not as much as we had predicted or hoped for, though the 2012 U.S. Supreme Court decision making the ACA’s Medicaid expansion optional for states knocked off between 3 to 5 million people who would otherwise have gotten coverage, and we would have come damn close to the 2010 projections.”

Despite its critics, the ACA “triggered a massive and broad set of initiatives to move the U.S. medical care delivery system away from fee-for-service payment that only rewards quantity of services provided and toward value-based payment that rewards quality, efficiency, and effectiveness,” McDonough stressed.

He said while “progress has been lower than anticipated or desired,” this incremental method of improvement has been in the right direction.

Ku said that the access given to lower income people has been impactful, given that “it’s poor people who run into the biggest problems if they can’t afford to have health insurance.”

Of course, in general, healthcare costs remain incredibly high in this country, and Ku added that is something not fixed by any kind of reform seen so far.

For instance, if you purchase a bronze-level plan through the marketplace, it brings with it high premiums. You could see yourself paying incredibly high rates before “receiving any kind of actual care,” he said.

Efforts to repeal the ACA

Since it passed, the ACA has been under attack. From the Obama years through the current first term of President Donald Trump, Republican lawmakers have tried very hard to repeal the law.

The problem is no real concrete replacement legislation has ever been proposed.

The journal Health Affairs writes that while efforts to fully repeal the ACA have failed in the past, come chipping away has occurred.

For instance, lawmakers in individual states have tried to prevent Medicaid expansion. In 2017, a congressional tax bill was passed that cut out the ACA penalty for people who didn’t have insurance.

Wallack said that the Supreme Court’s ruling that it was “optional” for states to expand Medicaid was also a blow to the ACA.

All of that being said, it remains standing despite immense opposition. Why?

“Honestly, I think while there have been attacks that have wounded the ACA, most of the attacks are in the ‘political ether,’ the President can’t even tell us what his plan is, [and there have] been crickets on the Republican side in terms of replacement,” Wallack said.

“Besides, who is going to kick 20 million people off their coverage, particularly now when you have all these people on unemployment like we’ve never seen in our lifetime?”

Wallack said that the economy’s decimation of small businesses also comes into play. Many will most likely have to drop coverage for employees.

In this period of “financial struggle they’ve never seen,” she suggests that Republican lawmakers might attempt to repeal the act, but she doesn’t think they would do it pre-election or even post-election.

“It’s political suicide to take that coverage away from people,” Wallack added.

Ku said perhaps the most vivid moment in the “repeal and replace” ACA debate came in 2017 when Sen. John McCain famously made his “thumbs-down” vote on the Senate floor, saving the ACA for another day.

Right now, McDonough cites the upcoming Supreme Court case that will have oral arguments from 20 Republican attorneys general on November 10, days after the presidential election.

That to him is the “primary existential threat” to the ACA. The death of Ginsburg “may or may not have a consequential impact on the fate of that lawsuit.”

He added that many “objective observers” on both sides predicted the effort would fail until Ginsburg’s death in September.

“Beyond that, since 2015, Donald Trump has promised more times than I can count that he will be unveiling some magnificent replacement system ‘within 2 weeks,’ ” McDonough said.

“His utter failure over 5 years to present a replacement system for the ACA is a recognition that the administration and Republicans in Congress have no idea what to do.”

What if the enemies of the ACA do succeed?

Ku said that it wouldn’t be an immediate shift — there wouldn’t be a moment when all healthcare access is suddenly stripped from people.

That being said, he stressed it could be “chaos” if efforts to repeal the law succeeded without any clear replacement system put in place.

For people with preexisting conditions and for low-income individuals, he said it’s almost impossible to know what would happen in this kind of hypothetical situation.

Just yesterday, Trump announced his version of healthcare reform, which doesn’t offer much change from what exists. He will sign executive orders to protect preexisting conditions and prevent so-called “surprise billing,” reports NBC News.

The catch? As detailed above, preexisting conditions are already protected by the ACA. Think of it as somewhat of a relabeling of something that already exists.

What might the future hold for the ACA?

During the 2020 Democratic presidential primaries, contenders were divided between embracing a single-payer plan, like those advocated by Sens. Bernie Sanders and Elizabeth Warren, and expansions upon the ACA, as supported by former Vice President Joe Biden, who is now the nominee competing against Trump.

Biden has made adding a government-paid public option to the ACA, which would compete against private insurance, part of his platform.

Wallack and Ku said it all depends on the makeup of the new Congress whether such a proposal would come into existence, even if there were a Biden presidency.

Wallack said a public option would be straightforward if it just means expanding on eligibility requirements for existing programs.

For instance, rather than Medicare eligibility standing at age 65, it could be dropped down to age 55 or 50 years. However, some resistance to expansion of Medicare comes from doctors who say it doesn’t pay enough as private insurance companies.

She said it would be more controversial if a large portion of the population shifted from employer coverage to a Medicaid buy-in. She said Medicaid typically is “bottom of the barrel” for physician payments, and that would cause more pushback from providers.

McDonough said that if Democrats control the White House and both chambers of Congress in January 2021, we will see “significant legislation” to expand affordability of healthcare and access to financial assistance for people who can’t afford insurance at all today.

This could include a public option or lowering Medicare eligibility.

If this doesn’t happen and there’s a more “divided government,” he added that “prospects for significant reforms are starkly diminished, and we can expect to see continuation of the minimalist trench warfare witnessed since 2010 — excepting for 2017, when Trump and [Republicans] attempted total repeal.”

Ku added that the big issue at hand is COVID-19 and the great health disparities it’s revealing and entrenching.

He stressed that it’s an unfortunate distraction there even is a fight over repealing or maintaining the ACA as a pandemic rages on. Particularly vulnerable groups to COVID-19, like immigrants who are uninsured, are the groups most ignored by our system right now, he said.

“I wish the real public policy right now was how to fix the problems occurring that we could fix now. They could be fixed relatively inexpensively, without big fights,” Ku explained.

“There are other things we can do to ensure we can fill gaps in our current system,” Ku added.

“Look, the ACA narrowed gaps, and I think we can do a better job of narrowing those gaps to make the overall public safer. But things get in the way of those discussions.”

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