Ten years ago this month, the Affordable Care Act (ACA) was signed into law. Since then, the law has transformed the American health care system by expanding health coverage to 20 million Americans and saving thousands of lives. The ACA codified protections for people with preexisting conditions and eliminated patient cost sharing for high-value preventive services. And the law goes beyond coverage, requiring employers to provide breastfeeding mothers with breaks at work, making calorie counts more widely available in restaurants, and creating the Prevention and Public Health Fund, which helps the Centers for Disease Control and Prevention (CDC) and state agencies detect and respond to health threats such as COVID-19.
Despite the undeniably positive impact that the ACA has had on the American people and health system, President Donald Trump and his allies have been on a mission to dismantle the law and reverse the gains made over the past decade—first through Congress and now through a lawsuit criticized by legal experts across the political spectrum. Even if the U.S. Supreme Court rules the ACA constitutional after it hears the California v. Texas health care repeal lawsuit this fall, President Trump’s administration cannot be trusted to put the health of the American people ahead of its political agenda. Trump’s administration hasn’t delivered on Trump’s commitment to “always protect patients with pre-existing conditions.”
The consequences of ACA repeal would be dire:
- Nearly 20 million people in the United States would lose coverage, raising the nonelderly uninsured rate by more than 7 percent.
- 135 million Americans with preexisting conditions could face discrimination if they ever needed to turn to the individual market for health coverage.
- States would lose $135 billion in federal funding for the marketplaces, Medicaid, and the Children’s Health Insurance Program (CHIP).
- Insurance companies would no longer be required to issue rebates when they overcharge Americans. In 2019, insurance companies returned $1.37 billion in medical loss ratio rebates to policyholders.
- The tax revenue that funds the expanded health coverage under the ACA would become tax cuts for millionaires, who would receive an average of $46,000 each.
As the nation awaits a final ruling on the lawsuit, the Center for American Progress is celebrating how the ACA has helped the American people access affordable health care in the past decade. In honor of the law’s 10th anniversary, here are 10 ways in which it has changed Americans’ lives for the better. Each of these gains remains at risk as long as the Trump administration-backed lawsuit remains unresolved.
1. 20 million fewer Americans are uninsured
The ACA generated one of the largest expansions of health coverage in U.S. history. In 2010, 16 percent of all Americans were uninsured; by 2016, the uninsured rate hit an all-time low of 9 percent. About 20 million Americans have gained health insurance coverage since the ACA was enacted. The ACA’s coverage gains occurred across all income levels and among both children and adults, and disparities in coverage between races and ethnicities have narrowed.
Two of the biggest coverage expansion provisions of the ACA went into full effect in 2014: the expansion of Medicaid and the launch of the health insurance marketplaces for private coverage. Together, these programs now cover tens of millions of Americans. Nationwide, 11.4 million people enrolled in plans for 2019 coverage through the ACA health insurance marketplaces. Medicaid expansion currently covers 12.7 million people made newly eligible by the ACA, and the ACA’s enrollment outreach initiatives generated a “welcome-mat” effect that spurred enrollment among people who were previously eligible for Medicaid and CHIP.
2. The ACA protects people with preexisting conditions from discrimination
Prior to the ACA, insurers in the individual market routinely set pricing and benefit exclusions and denied coverage to people based on their health status, a practice known as medical underwriting. Nearly 1 in 2 nonelderly adults have a preexisting condition, and prior to the ACA, they could have faced discrimination based on their medical history if they sought to buy insurance on their own.
The ACA added a number of significant new protections for people with preexisting conditions. One group of reforms involved changes to the rating rules, prohibiting insurers from making premiums dependent on gender or health status and limiting their ability to vary premiums by age. The ACA also established guaranteed issue, meaning that insurers must issue policies to anyone and can no longer turn away people based on health status.
Another crucial protection for people with preexisting conditions is the ACA’s requirement that plans include categories of essential health benefits, including prescription drugs, maternity care, and behavioral health. This prevents insurance companies from effectively screening out higher-cost patients by excluding basic benefits from coverage. The law also banned insurers from setting annual and lifetime limits on benefits, which had previously prevented some of the sickest people from accessing necessary care and left Americans without adequate financial protection from catastrophic medical episodes.
3. Medicaid expansion helped millions of lower-income individuals access health care and more
To date, 36 states and Washington, D.C., have expanded Medicaid under the ACA, with 12.7 million people covered through the expansion. While the Medicaid program has historically covered low-income parents, children, elderly people, and disabled people, the ACA called for states to expand Medicaid to adults up to 138 percent of the federal poverty level and provided federal funding for at least 90 percent of the cost.
Medicaid expansion has led to better access to care and health outcomes for low-income individuals and their families across the country. A large body of evidence shows that Medicaid expansion increases utilization of health services and diagnosis and treatment of health ailments, including cancer, mental illness, and substance use disorder. Medicaid expansion is associated with improvements in health outcomes such as cardiac surgery outcomes, hospital admission rates for patients with acute appendicitis, and improved mortality rates for cardiovascular and end-stage renal disease. Beyond health outcomes, evidence points to improved financial well-being in Medicaid expansion states, including reductions in medical debt and improved satisfaction with one’s current financial situation. A study that assessed eviction rates in California found that Medicaid expansion is “associated with improved housing stability.”
Evidence shows that Medicaid expansion saves lives. According to a 2019 study, Medicaid expansion was associated with 19,200 fewer deaths among older low-income adults from 2013 to 2017; 15,600 preventable deaths occurred in states that did not expand Medicaid. As the Center on Budget and Policy Priorities points out, the number of adults ages 55 to 64 whose lives would have been saved in 2017 had all states expanded Medicaid equals about the number of lives of all ages that seatbelts saved in the same year.
4. Health care became more affordable
The ACA’s signature health insurance marketplaces—portals for people purchasing coverage on their own—launched in fall 2013 and made financial assistance for private coverage newly available. In 2019, nearly 9 out of 10, or 87 percent, of marketplace enrollees qualified for financial help with premiums, and roughly half—54 percent—received reduced cost sharing. Although the average plan premium was $612 per month, the average enrollee owed just $87 per month after applying the ACA’s financial assistance.
In addition to enabling states to expand Medicaid to millions of newly eligible low- and middle-income Americans, the ACA “included provisions to streamline eligibility, enrollment, and renewal processes” for Medicaid and CHIP. These changes make it easier for children to be enrolled in and stay covered by coverage with little or no cost sharing. The ACA also accelerated the development and promotion of data-driven systems: As of January 2019, all states allow potential Medicaid beneficiaries to apply online and most allow for application by phone.
Across nearly all health plans, both public and private, the ACA eliminated copayments and other forms of cost sharing for preventive services. This provision allows beneficiaries to seek contraception; screenings for cancers, blood pressure, cholesterol, and other illnesses; and immunizations without out-of-pocket payments. In addition, the ACA holds private insurance companies accountable for charging fair premiums, whether for individual market policies or for employer-sponsored coverage. The medical loss ratio (MLR) rules require insurance companies to return money to policyholders and employers if their health plans spend less than 80 percent to 85 percent of premium funds on medical care. In 2019, insurers returned $1.37 billion in MLR rebates to consumers for overpricing premiums relative to actual medical care.
The evidence shows that better affordability translates into better access. Between 2010 and 2018, the share of nonelderly adults who skipped a medical test or treatment fell 24 percent. ACA implementation reduced the probability of not receiving medical care due to cost by about one-quarter, and it dramatically increased the share of people who reported having a usual place of care.
5. Women can no longer be charged more for insurance and are guaranteed coverage for services essential to women’s health
Prior to the ACA, women faced unique barriers to adequate care. Insurers in the individual market could charge women up to 1.5 times more than men for health insurance, a discriminatory practice known as gender rating, and insurers treated pregnancy as a preexisting condition. Plans could also exclude critical women’s health benefits from coverage: In 2011, 62 percent of individual market enrollees were in plans without maternity coverage. The ACA outlawed gender rating and prohibited insurers from discriminating against people with preexisting conditions. The latter is a crucial protection for women: About 1 in 2 girls and nonelderly women have a preexisting condition.
The ACA mandates that plans include maternity coverage and makes key preventive services available without cost sharing, including breastfeeding support services and supplies; annual well-woman visits; and screenings for cervical cancer, HIV, and interpersonal and domestic violence. Thanks to the ACA, about 61 million women nationwide can access contraception without any out-of-pocket cost. One study estimated that the ACA’s contraception benefit has saved women at least $1.4 billion annually on birth control pills alone.
The ACA also recognized that supporting maternal and infant health required policy changes beyond health coverage. The law mandates that employers provide breastfeeding mothers break time and a private space to express milk during the workday.
6. Young adults and children have greater access to coverage
One of the first ACA provisions to go into effect was the rule guaranteeing young adults the right to stay on a parent’s insurance until age 26. About 2.3 million young adults—a group that is less likely to have an offer of employer-sponsored insurance than their older counterparts—gained coverage under the ACA’s dependent coverage provision. Later on, additional young adults gained coverage though marketplace financial assistance and Medicaid expansion. As a result, the uninsured rate among people ages 18 to 24 fell by half, dropping to 15 percent in 2017.
The ACA raised standards to ensure that children in low- and middle-income families can access health coverage. It extended the minimum Medicaid eligibility level for children to 138 percent of the federal poverty level and mandated that states “use a uniform definition of income” to set standards for children’s coverage. About one-quarter to one-third of new enrollees under Medicaid expansion are children. The ACA also defined pediatric dental and vision care as part of essential health benefits, ensuring that kids covered through both the marketplace and Medicaid have coverage for those services. Further, expanding coverage to adults—through the ACA marketplaces and Medicaid expansion—helps parents stay healthy and provides financial security to the entire family.
7. The ACA improved access to prescription drugs
Prior to the ACA, 9 percent of individual market plans did not cover prescription drugs. The ACA expanded drug coverage by requiring marketplace plans to “cover at least one drug in each drug class” and to count out-of-pocket drug expenses toward a beneficiary’s deductible. By expanding Medicaid eligibility as well as broadening the Medicaid Drug Rebate Program, the ACA gave more low-income Americans access to brand-name and generic drugs and lowered the costs for taxpayers. The ACA also expanded the 340B drug discount to include more providers, including critical access hospitals and rural referral centers.
The ACA also laid out a process for faster Food and Drug Administration approval of biosimilars, biologic drugs that are essentially analogous to generic versions of branded drugs. By encouraging competitors for high-cost biologic drugs, the ACA rules on biosimilars can potentially help bring down the price of these types of prescription drug costs and help make new therapies available to patients who need them. These are all important steps toward drug affordability, but there is much more work to be done.
8. Rural communities have benefited from the ACA
Medicaid expansion is particularly important for coverage and the sustainability of the health care system in rural areas. Rural residents are more likely to be covered by Medicaid: 22.5 percent of rural Americans have Medicaid coverage, including nearly half of all rural children. Medicaid expansion reduced the amount of uncompensated care that hospitals provide, boosting the financial viability of rural hospitals relative to their counterparts in nonexpansion states. While more than 100 rural hospitals have closed in the past decade, the closures have occurred disproportionately in nonexpansion states.
The ACA provides patients and the health care system with resources to combat the opioid crisis, which has hit rural areas particularly hard. The ACA requires plans to cover substance use disorder (SUD) treatment as an essential health benefit. Without this requirement, only 1 in 3 people covered through the individual market would have had access to SUD treatment.
Many people in rural and other medically underserved communities rely on community health centers and other Federally Qualified Health Centers (FQHCs) for comprehensive primary care. Federal grants provide 1 in 5 revenue dollars that community health centers receive, and 70 percent of that funding comes from the Health Center Trust Fund set up by the ACA.*
9. The ACA lowered costs for seniors on Medicare
Altogether, ACA programs have saved seniors more than $20 billion on prescription drugs since the law’s passage, and seniors have benefited from no-cost preventive services such as cancer screenings and wellness visits. By closing the Medicare Part D coverage gap—also known as the “donut hole”—the ACA has helped lower beneficiaries’ out-of-pocket costs for prescription drugs. Prior to the ACA, seniors who reached a certain level of prescription drug spending faced a coverage gap, in which they had to pay the full cost of all prescription drugs, before the plan’s catastrophic coverage kicked in. Before the ACA closed the coverage gap, about 5 million Medicare enrollees fell into it.
The ACA also invested in other improvements for the Medicare program by establishing the Center for Medicare and Medicaid Innovation, which is responsible for developing ways to improve patient care and lower health care costs.
10. Protections for disabled people were enhanced
Millions of Americans are disabled and rely on the ACA’s consumer protections and coverage. Prior to the ACA, people would be functionally uninsured after hitting arbitrary annual or lifetime coverage limits. The ACA prohibits insurers from setting coverage limits, as well as from denying coverage or raising prices for preexisting conditions.
Medicaid expansion has helped many disabled people and caregivers access care based on their income status. Not all disabled people qualify for the traditional Medicaid disability pathway. Medicaid expansion allows disabled people to join the workforce without jeopardizing their Medicaid benefits and gives low-income workers a fallback option for coverage if they lose access to employer-sponsored insurance.
Essential health benefits help disabled people access necessary services. Prior to the ACA, 45 percent of individual market plans did not cover SUD services and 38 percent did not cover mental health care. Following ACA implementation, people with mental health conditions became significantly less likely to report unmet need due to cost of mental health care.
The ACA has helped millions of Americans gain insurance coverage, saved thousands of lives, and strengthened the health care system. The law has been life-changing for people who were previously uninsured, have lower incomes, or have preexisting conditions, among other groups. Yet even as the ACA’s historic accomplishments are celebrated, it is important to note the high stakes of the dedication that the Trump administration and its allies have shown to dismantling the ACA and reversing a decade of progress.
* Authors’ note: The funding has had to be extended twice and will have to be extended again in May 2020.
Nicole Rapfogel is a research assistant for Health Policy at the Center for American Progress. Emily Gee is the health economist of Health Policy at the Center. Maura Calsyn is the managing director of Health Policy at the Center.