Eight dollars for a carton of eggs. Recession warnings. Massive proposed cuts to Medicaid. When things look particularly grim, it helps to take a moment and reflect on what’s going right in the world. And one of those things is the 15th anniversary of the Affordable Care Act (ACA). That landmark health law was signed by President Obama on March 23, 2010, and fundamentally changed the health insurance landscape. Here are some of the ACA’s reforms that have led to the lowest uninsured rate in history, and protect people in this time of great uncertainty:
Preventing Discriminatory Practices
One of the fundamental goals of the ACA was to make it so that everyone, no matter their health status, could access quality and affordable health insurance. Prior to the ACA, health insurers could discriminate against people deemed “risky” for high health costs (such as women of childbearing age) by charging higher premiums, refusing to cover treatment for preexisting health conditions, or even denying coverage based on health status.
The ACA prohibited these practices through federal standards such as guaranteed issue of coverage, a ban on preexisting condition exclusions, and rating rules that stop insurers from charging higher premiums to sick people. An estimated 27 percent of adults under age 65 have the kind of pre-existing condition that, before the ACA was passed, would have led an insurer to deny them coverage, such as diabetes, a cardiac condition, or a history of cancer within the last 10 years.
Providing Comprehensive Coverage
Before the ACA, even people who were healthy enough to obtain insurance were not necessarily able to buy comprehensive coverage; individual insurance policies often excluded or limited coverage for services like prescription drugs, mental health, and maternity care.
Under the ACA, most individual and small group health plans have to cover a set of services deemed “Essential Health Benefits.” These coverage requirements, which include benefits such as laboratory services, prescription drugs, mental health, maternity and pediatric care, and hospitalization, ensure that consumers have insurance policies that provide pathways, not road blocks, when they need health services. The ACA also requires health plans to cover recommended preventive services, such as child well visits, mammograms, and colonoscopies without cost-sharing.
Banning Coverage Limits
Before 2010, health insurance enrollees could “use up” their coverage, hitting either an annual or lifetime dollar limit. In 2009, the year before the ACA’s enactment, 89 percent of individual market enrollees and 59 percent of workers enrolled in employer coverage were subject to lifetime dollar limits on their benefits. If enrollees hit their limits, they could be exposed to exorbitant medical bills. In 2013, we met Martin A., a hemophiliac whose blood disorder treatment cost $60,000 each month. Before the ACA, Martin hit the lifetime coverage limit on three separate health plans. While he waited for his Medicare coverage to kick in, he had to resort to an older, less effective drug and delayed critical surgery. The ACA prohibited insurers from setting lifetime or annual dollar limits on coverage for people like Martin.
The numbers of people reporting problems paying medical bills declined dramatically after the ACA’s reforms went into effect. Although we still have a long way to go to eliminate medical debt and medical bankruptcy in this country, the ACA’s ban on coverage limits ensures that, in the event of expensive treatment regimens or a long hospital stay, consumers won’t have to worry about “capping out” their health insurance.
Reducing the Financial Strain of Premiums and Out-of-Pocket Costs
The ACA established health insurance Marketplaces for people without an offer of affordable employer coverage to find comprehensive health insurance. To make that insurance more affordable, it established income-based tax credits for premiums and cost sharing subsidies, as well as an expansion of Medicaid, which has been implemented on a state-by-state basis. In addition to financial assistance, the ACA limits the amount of annual out-of-pocket costs, such as copayments, coinsurance and deductibles, that a plan can impose on consumers. In 2021, Congress enhanced the premium tax credits, resulting in average premium savings of $700 per enrollee in 2024 and significantly boosting Marketplace enrollment.
Purchasing insurance and paying out-of-pocket costs can pose huge obstacles to obtaining health care services. Unfortunately, price inflation among consolidated provider systems is rampant, leading to higher premiums and cost-sharing for millions of Americans with private health insurance. However, the ACA’s Medicaid expansion, financial subsidies, and out-of-pocket maximum are helping millions of consumers afford the coverage and care that they need.
Reversing Historic Inequities in Health Care Access
Prior to enactment of the ACA, Black and Hispanic individuals were significantly more likely to be uninsured than white people. In 2013, before the full suite of ACA reforms was in effect, the uninsured rate for Black adults was 24.4 percent; for Hispanic adults it was 40.2 percent. White adults had a 14.5 percent uninsured rate. While a gap in coverage rates remains, the ACA has helped it to shrink considerably. Between 2013 and 2021, the coverage gap between Black and white adults dropped from 9.9 to 5.3 percentage points and the gap between Hispanic and white adults dropped from 25.7 to 16.3 points.
The Next 15 Years?
On its 15th anniversary, the ACA is hard at work, protecting consumers, setting minimum coverage standards, and providing premium tax credits and expanding Medicaid eligibility. These are the pillars of a system that has enabled access to affordable, comprehensive health insurance that simply didn’t exist in 2010. However, the ACA is facing a crucial test: Congress has proposed steep cuts that would result in millions losing Medicaid, the enhanced premium tax credits are slated to expire at the end of 2025, causing a projected 4 million people tp lose their health coverage, and the Trump administration is advancing policies that, by its own estimate, would kick up to 2 million Marketplace enrollees off their coverage. A lawsuit would, if successful, roll back consumers’ right to free preventive care. The ACA has faced similar challenges before, but they have been consistently beaten back because the American people have shown, again and again, that they value health coverage and they do not want it ripped away.