This article contains a correction.
The signage of the Affordable Care Act (ACA) on March 23, 2010, marked the beginning of transformation for the American health care landscape.* Fourteen years after its enactment, the ACA has successfully expanded access to health insurance to millions of Americans, increased coverage affordability, strengthened the value of health insurance, and established core consumer protections—such as prohibiting insurance denials for preexisting conditions—that Americans count on and overwhelmingly support.
The ACA has worked largely as intended, fulfilling its primary goals of expanding access and making coverage more affordable. As a result, the law’s hard-fought and frequently challenged reforms, rights, and benefits have become a part of the status quo. Perhaps because of the ACA’s successes, public knowledge and attribution of the law’s provisions is dwindling. While this is actually a good sign of the ACA’s widespread impact, in light of renewed partisan rhetoric around repeal, that disconnect is a major source of concern for protecting and preserving the ACA moving forward.
The ACA has worked largely as intended, fulfilling its primary goals of expanding access and making coverage more affordable.
This column provides a refresher on some of the ACA’s key accomplishments, reiterates what is at stake if it were to be repealed, and offers recommendations for key and immediate policy actions to build on its successes.
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The ACA’S key accomplishments
The ACA halved the number of uninsured, strengthened coverage, and codified consumer protections.
The ACA has led to historic coverage and affordability gains
One of the ACA’s most significant achievements has been expanding affordable health coverage to nearly 40 million Americans. As a result, the ACA helped drop the nation’s uninsured rate to an all-time low of 7.2 percent in 2023. Provisions such as expanded Medicaid eligibility and allowing young adults to stay on their parents’ plans until age 26 opened new pathways to comprehensive coverage for millions of previously uninsured Americans. The law’s premium tax credits and cost-sharing reductions made buying and using insurance more affordable for lower-income adults and families who buy insurance on their own by reducing their premiums and out-of-pocket costs. Enhanced financial assistance made possible by the American Rescue Plan Act (ARPA) of 2021 and extended via the Inflation Reduction Act of 2022 further increased coverage affordability, including by eliminating the “subsidy cliff” that made it financially challenging for middle-income families to purchase marketplace insurance.
The ACA has strengthened health insurance benefits
In addition to improving coverage access and affordability, the ACA required insurers to offer comprehensive coverage. Covered benefits varied before the ACA: Insurers could largely choose what to cover, and many individuals were enrolled in plans that did not cover key services including maternity care, substance use treatment, mental health services, and prescription drugs. The ACA required, for the first time, insurers to cover 10 essential health benefits. In addition, the ACA made evidence-based preventive services—such as vaccines, cancer screenings, wellness visits, and birth control—available to people with no out-of-pocket costs. This focus on prevention has helped generate savings, with one study finding that women saved $1.4 billion in out-of-pocket costs on birth control in the first year of the coverage requirement alone.
The ACA’s essential health benefits and preventive services requirement
Beginning on January 1, 2014, Americans had access to comprehensive health insurance thanks to the ACA’s requirement that health plans cover these 10 essential health benefits:
- Outpatient services
- Emergency services
- Hospitalization
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric oral and vision care
For policies beginning on or after September 23, 2010, the ACA required health plans to cover the following high-value preventive services with zero out-of-pocket costs:
The ACA established critical consumer protections
The ACA prohibited insurance industry practices that regularly harmed consumers prior to 2010. Pre-ACA, an estimated 50 million to 129 million people with preexisting conditions—including pregnancy—could either be denied coverage or forced to pay higher premiums; women were routinely charged more than men for the same coverage; young adults largely aged out of their parents’ coverage at 19; and more than 100 million Americans were enrolled in plans with lifetime or annual dollar limits. Nearly 20,000 individuals reached these limits each year—restricting their care when they needed it the most.
The ACA also implemented appeals protections, expanding people’s rights and establishing a standardized process to appeal decisions made by their health insurance plan, particularly when a claim is denied. Previously, one’s right to appeal insurer decisions varied by state and the type of employer or individual coverage they had. The ACA both required broadened internal appeals rights and instituted the right to external review by an independent entity in some instances as an additional layer of consumer protection.
ACA repeal would undo 14 years of progress
In spite of these and many other successes, the ACA continues to experience divisive, partisan pushback and calls for repeal. Yet many of the law’s core provisions remain overwhelmingly popular, with the majority of Americans considering it “very important” to keep those provisions in place—even if they are unaware that these provisions originated from the ACA. A 2024 KFF poll found that half of the public wants to see the next Congress or president expand the ACA. Repeal, especially without a comprehensive replacement plan, would strip away more than a decade’s worth of progress, leaving individuals and families once again vulnerable to discriminatory and severely limited coverage and without the core insurer protections established by the ACA that all Americans rely on today. Millions of people’s access to free preventive care is already at risk due to one of the latest legal challenges to the Affordable Care Act, Braidwood v. Becerra.
Repeal, especially without a comprehensive replacement plan, would strip away more than a decade’s worth of progress.
Policymakers must build on the ACA’s pillars of affordable and accessible care
In the 14 years since its enactment, the ACA has laid a strong foundation of coverage expansion, improved affordability, and enhanced consumer protections. As policymakers seek to build on—rather than tear down—this legacy, they should focus their attention on ensuring affordable and accessible coverage for all Americans. Two immediately urgent opportunities to do so include closing the Medicaid coverage gap and making temporary marketplace subsidy enhancements permanent.
Closing the Medicaid coverage gap
The ACA’s expansion of Medicaid eligibility to adults with family incomes up to 138 percent of the federal poverty level resulted in more than 18 million Americans newly enrolling in Medicaid. In addition to coverage gains, Medicaid expansion has helped advance access to care, improve health outcomes, support financial security, and reduce health disparities. However, 10 states—Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming—have yet to adopt expansion. As a result, there are still 1.5 million uninsured, low-income Americans in the coverage gap—those who do not qualify for either Medicaid or financial assistance for marketplace coverage.
Congressional leaders and policymakers in the remaining 10 states should give renewed and serious consideration to closing the coverage gap. ARPA provided additional incentives for Medicaid expansion to nonexpansion states in the form of enhanced federal financing. KFF estimates that these incentive funds are more than two times larger than new state expansion costs. This unprecedented federal support has helped spur momentum: In 2023 North Carolina became the 40th state to adopt Medicaid expansion, and other holdout states are also exploring expansion. Helpfully, there has been enhanced bipartisan support for expansion this year: Mississippi currently has expansion legislation under consideration, although efforts to attach work requirements may be counterproductive and blunt expansion impact. Based on previous Center for American Progress estimates, Medicaid expansion in the remaining 10 states** would save 6,340 lives annually, reduce evictions by over 44,000 each year, and cut medical debt by $1.8 billion. Nonexpansion states have a unique opportunity to maximize federal support and close the coverage gap.
Extending premium subsidy enhancements
Enhanced financial assistance, made possible by ARPA and extended by the Inflation Reduction Act, reduced enrollee premiums and made coverage more affordable for individuals and families in a wider range of incomes. In 2023, 1.4 million middle-income individuals who were previously ineligible for premium tax credits benefited from these enhancements. That same year, subsidized monthly premiums fell by 21 percent, saving individuals more than $800 on average that year thanks to the expanded financial assistance. Reextending or making this expanded assistance permanent would solidify the ACA’s coverage and affordability gains.
Without Congressional action, the enhanced premium tax credits will expire on December 31, 2025, triggering coverage losses and premium increases. The Congressional Budget Office (CBO) projects that if the enhancements are not extended, marketplace enrollment would decline by 3.2 million and the number of uninsured would increase by 1.2 million between 2025 and 2026. Marketplace premiums would also increase: The Center on Budget and Policy Priorities (CBPP) estimates that the expiration of enhanced tax credits would cost a family of four living on an annual income of $125,000 nearly $7,700 more for their annual marketplace premium. To avoid market instability and consumer confusion regarding steep premium increases during the 2026 open enrollment period, which will begin in November 2025, Congress should act swiftly to extend the subsidy enhancements.
Conclusion
The ACA transformed the American health care landscape by greatly expanding access to comprehensive, affordable health insurance; strengthening health insurance benefits; and codifying touchstone consumer protections enjoyed by all Americans today. Fourteen years later, public support for these provisions remains high, but the public’s attribution of them to the ACA is waning, which makes calls for its repeal particularly concerning. Rather than bringing the country backward by undoing these achievements, it is critical that policymakers continue to build on the ACA’s foundational successes. By closing the Medicaid coverage gap and extending the enhanced financial assistance for families set to expire next year, policymakers can take two immediate steps to further expand coverage access and increase affordability.
*Correction, March 22: This article has been updated to reflect that March 23, 2010, is the date the ACA was signed rather than passed.
**Authors’ note: These numbers exclude North Carolina from the totals in CAP’s 2021 analysis to reflect the state’s expansion in 2023.
The authors would like to acknowledge Nicole Rapfogel, Health Policy Analyst, for her contributions.