Five years ago, the Affordable Care Act (ACA) — 906 pages of some of the hardest-fought and farthest-reaching legislation in a generation — began to take effect.
Not all elements of the complex law have yet rolled out, but the biggest changes happened two years ago. With enrollment for its signature insurance plans opening up again on November 1, we thought it was time for a progress report on the reform effort.
Have Americans’ health insurance coverage and, more importantly, their health improved at all?
Have healthcare costs — which had been skyrocketing in recent years — come more into line with the rest of the economy, as supporters hoped? Or has President Obama’s signature effort killed jobs and made it more difficult for Americans to get the care they need, as its opponents warned?
The law has reduced the share of people without health insurance in the United States by more than 10 percentage points since 2013. Some 16 million previously uninsured Americans have gained coverage since the law passed in 2010, putting coverage rates higher than they have been at any time in the last two decades.
The expansion of Medicaid benefits to people with incomes of up to 138 percent of the federal poverty level added insurance coverage to 12 million people.
“And that’s essentially free coverage,” Christine Eibner, Ph.D., a senior economist at the Rand Corporation, reminded.
However, after the Supreme Court’s decision that states couldn’t be forced to expand Medicaid, even on the federal government’s dime, 3.1 million people lost access to coverage they would otherwise have received.
The ACA sought to put healthcare within reach for people with lower incomes, especially those who don’t have access to employer-based insurance coverage. It’s done that.
People with low incomes have seen the biggest jump in rates of coverage, from 64 percent in 2010 to 76 percent last year. Before healthcare reform, African Americans and Hispanics were less likely than their white counterparts to have health insurance. Those gaps have shrunk, though coverage among Hispanics remains low.
Young adults have historically been less likely to have employer-based care. They’re more likely to have jobs that don’t offer benefits and they change jobs more frequently, according to Sara Collins, Ph.D., the Commonwealth Fund’s vice president of healthcare coverage and access.
The ACA mandates that everyone 26 years old or younger be allowed to remain as dependents on their parents’ healthcare plans, which has resulted in 3 million more young people covered. Young people from 19 to 25 are no longer more likely than their older peers to be uninsured.
However, people who are well off have not seen much financial benefit from the law because they don’t qualify for tax-based cost-offsets for premiums and out-of-pocket expenses.
The number of people who now have some sort of health insurance policy is up, but does that mean the quality of their coverage is any good?
Many say that the overall quality of health insurance benefits has improved. More than two-thirds of adults who bought plans through the new insurance marketplace rated their health insurance excellent, very good, or good.
The ACA set an “essential benefits” minimum that all healthcare exchange policies have to meet. It includes some areas, like mental healthcare and maternity care, which were often left out of skimpier plans. The law also requires that basic preventive care be offered at no out-of-pocket cost for the patient.
Researchers say more than 8 million others have more comprehensive coverage now than they did in 2010.
With all of the newly insured, are there enough doctors to go around?
It appears there are. According to a NEJM study, Medicaid beneficiaries now have slightly better access to primary care appointments than they did before. The ACA brought no change in how long a person with private insurance has to wait for a new-patient appointment, the study found.
It’s not just scheduling an appointment that keeps some people from getting care. It’s paying for it.
Has the ACA made healthcare more affordable?
Premiums for health insurance plans on marketplace exchanges went up slightly this year. Did that mean the reform was failing? Probably not. It does indicate that healthcare costs haven’t stopped increasing entirely under the ACA. But they’re going up more slowly now.
“Healthcare cost growth nationally slowed from 2008 to 2013 and it kicked up from 2013-2014,” Eibner explained. “But it still didn’t rise back up to the levels we were seeing in early 2000s. Whether that has anything to do with the ACA or not, it’s really hard to say. There are so many different competing trends.”
There are concerns about ballooning deductibles for ACA plans. Consumers who bought insurance through an exchange were more likely to have out-of-pocket requirements of $1,000 or more than those who got insurance coverage through their jobs.
For silver, or middle-tier plans, the average annual medical deductible in 2015 was $2,563. People who make up to two-and-a-half times the federal poverty level can get cost-sharing subsidies through the federal government if they buy at least a silver policy. But many may not know that and opt for a cheaper bronze plan, Collins said.
Deductibles have also been rising in employer-based plans since before the ACA took effect.
“The ACA didn’t slow it, but it didn’t cause it either,” Eibner said.
And then there’s another way experts have tried to measure affordability: healthcare debt.
The number of adults who reported problems paying their medical bills fell from 75 million people in 2012 to 64 million in 2014, according to a Commonwealth Fund survey.
With mixed findings, out-of-pocket costs are the main issue that pundits are watching going into 2016. If they rise enough, healthier people will shy away from the new marketplace coverage.
“It is too soon to know the magnitude of these effects on enrollment, but growing evidence indicates that there are significant reasons for concern,” according to an Urban Institute white paper.
What really matters at the end of the day is whether Americans have gotten the care they need — in other words, are we any healthier now than we were in 2010?
It’s too soon to really measure health outcomes. But early signs point in the right direction.
Many Americans have made visits to the doctor and filled prescriptions that they report they couldn’t have afforded before.
Harvard researcher Dr. Benjamin Sommers, Ph.D., pored through the answers to a daily national Gallup poll on health and well-being. Comparing answers before the ACA and after its first two enrollment periods, Sommers found that the percentage who said they didn’t have a doctor or didn’t have access to medicine fell.
More importantly, fewer respondents reported poor or fair health. And a smaller percentage reported that their activities were limited by their health.
The Centers for Disease Control and Prevention (CDC) found another way to measure Americans’ overall health. Researchers there focused on a single marker of health: blood pressure. Blood pressure is easy to measure and closely tied to heart disease, the top cause of death in the United States.
The CDC predicted that with more people able to afford blood pressure medication, there would be 111,000 fewer cases of heart disease, 63,000 fewer strokes, and 95,000 fewer deaths by 2050.
The provision that extended parents' plans to young adults up to age 26 also seems to have had results. After the expansion took effect in 2010, cervical cancers among women in the age group were caught more often at their early, more treatable stages, according to a November study published in the Journal of the American Medical Association.* Among women aged 26-34, the percent of cases caught early remained the same.
“It’s a very remarkable finding, actually,” researcher Dr. Ahmedin Jemal, told the New York Times. “You see the effect of the A.C.A. on the cancer outcomes.”
Republicans have repeatedly tried to repeal or weaken Obamacare. But only one punch really landed: the court challenge to mandatory Medicaid expansion.
The Supreme Court found in favor of the opponents in 2012, ruling that the federal government could not require states to broaden Medicaid. Nineteen states, all Republican-led, exercised their right to leave Medicaid eligibility requirements alone.
That left more than 4 million people with no coverage and no help getting it. They made too much money to qualify for Medicaid, but not enough to qualify for help to buy new private insurance plans.
Opposition — for instance, a Republican in the White House — could still kill the ACA. But that seems increasingly unlikely.
“It could get repealed, but I think it would be hard because people have started to see benefits,” Eibner said.
But given all the animosity the law has generated, what are its flaws?
“In reviewing the literature and evidence, it seems like there’s a lot of success or no impact, but there’s not a lot of ‘this went really badly,’” Eibner said.
For example, there’s no evidence it’s killed jobs by pushing businesses to cover all employees who work 30 hours or more, an Urban Institute investigation concluded.
The biggest problem with the ACA is not that it didn’t help, but that it didn’t help enough.
“One criticism you might raise is that this didn’t go far enough,” Eibner said. “There are still like 35 million people who are uninsured in the U.S., partly because Medicaid expansion didn’t happen in all states.”
But Collins expects that if the ACA has more positive progress reports, more Republican states will swallow their ideological pride and expand Medicaid rolls. On November 3, 2015, after this article was first published, Montana expanded its Medicaid coverage.
“It’s likely we’ll continue to see states finding ways around the political logjam,” Collins said.
Sources: In putting together this progress report, Healthline relied heavily on research done by the Commonwealth Fund, the Kaiser Family Foundation, and the Rand Corporation. The main sources for the timeline were the Kaiser Family Foundation and the AFL-CIO.
*This scorecard has been updated since it was originally published.