A pandemic. A Supreme Court challenge (again). A presidential election campaign — this time with attacks from the left as well as the right.
Ever since President Barack Obama signed the Affordable Care Act into law 10 years ago Monday, it has faced legislative, legal and political attacks. The landmark health law, nicknamed Obamacare, has withstood more than 60 votes to repeal it from Republican-controlled Congresses, two Supreme Court decisions, the gutting of one of its main provisions (the tax penalty for not having insurance) and a president who campaigned on promises to get rid of it.
But for all the challenges the law has weathered, no moment has seemed as existential as now. As the coronavirus pandemic tests the American health system in ways few could have imagined, an increasingly conservative Supreme Court is preparing to hear another case, backed by the Trump administration, challenging the law’s constitutionality. At the same time, the left wing of the Democratic Party, a major force behind the law’s passage, has grown impatient with it and is demanding more radical change, to a single-payer, government-run health insurance system.
On the anniversary of the law, veteran health policy reporters at The New York Times looked beyond the political and legal debate to try to answer one question: How has the law worked in its first decade?
It’s greatly expanded coverage.
The law did not achieve universal coverage, but it brought about a historic drop in the number of Americans without health insurance.
When it was passed, nearly a quarter of Americans (22.3%) between 18 and 64 were uninsured. By 2016 — just two years after the law’s insurance marketplaces opened and states were allowed to expand Medicaid to more low-income people — that rate had plunged to 12.4%. In all, about 20 million more people have coverage now than before the law.
“In addition to making medical treatment available for many who already had chronic and infectious conditions, the ACA offered preventive care to millions of people who otherwise might have become ill,” said John Auerbach, president and chief executive of Trust for America’s Health, a nonpartisan health policy group. “It’s also resulted in improved access to coverage and care for people of color, reducing — although not eliminating — longstanding disparities.”
The biggest advance has been the huge increase in coverage of poor people. The law originally required states to expand Medicaid, the government health insurance program for low-income Americans, with the federal government paying almost all of the bill. In 2012, the Supreme Court ruled that states could not be compelled to do so, and the provision became optional, creating a disparity that remains stark.
Still, all but 14 states have now expanded the program, and the results have been significant: Medicaid enrollment increased by about 13 million, or 34%, in the so-called expansion states between 2013 and 2019, according to federal data. The uninsured rate for poor adult citizens with no dependent children — a group that had often been ineligible for Medicaid — plummeted, dropping to 16.5% in 2015 from 45.4% in 2013, according to the Urban Institute.
Overall, the largest coverage gains under the ACA have been among Hispanic, black and Asian patients — many of the groups that had the highest uninsured rates before the law, the Kaiser Family Foundation found.
For some, the coverage has changed their lives profoundly. Jean Jackson, 64, of Danville, Virginia, had to retire early from her job as a cooling inspector in 2017 because she had cataracts that made it impossible for her to drive at night, when her shift took place. That left her uninsured until January 2019, when Virginia expanded Medicaid.
By then her cataracts had grown large enough to require surgery. She had them removed within months of getting Medicaid and now can again see well enough to drive after dark, allowing her to volunteer and attend community meetings, activities she said were vital to her well-being.
“It was stressful, yes it was,” Jackson, who is black, said of not having health insurance. “It was very frightening, not being able to see.”
But for all the success, over the last couple of years, the uninsured rate has started creeping back up. In 2018, 8.5% of the population did not have health insurance, up from 7.9% the year before, the Census Bureau reported. It was the first increase since the Affordable Care Act passed, and came even as the economy was doing well. Researchers are trying to measure the impact on the uninsured rate of efforts by the Trump administration and Republicans in Congress to undermine the law, including eliminating the mandate requiring most people to have coverage and slashing the budget for marketing and programs that helped people learn about new insurance options.
The slippage has especially hurt children — a recent analysis of new census data by The Times found that the number of children without insurance rose by more than 400,000 between 2016 and 2018.
Now, as the coronavirus sweeps through the country, many state officials are relying on the Affordable Care Act to provide health coverage for residents who have none. On Friday, California became one of the latest states to set up a special enrollment period so people can sign up for insurance on their state-run marketplaces, and the Trump administration is considering reopening enrollment in the larger federal marketplace, which serves most states, for a limited period.
It hasn’t curbed costs enough.
For many Americans, the “Affordable” part of the Affordable Care Act has seemed like an empty promise, as premiums, deductibles and other out-of-pocket costs continue to be an extraordinary burden on millions of households.
But the law has made health care far more affordable in a number of less conspicuous ways.
For Marque Dailey of Dallas, 35, who has multiple sclerosis, the Affordable Care Act was the only way to get private insurance. Before the law, insurance companies were allowed to deny coverage to people like him who had expensive medical conditions, or to charge such a high price that many could not afford the premiums. About half of all Americans had such preexisting conditions, including high blood pressure or lung disease, that resulted in their being denied or potentially priced out of coverage, according to one federal estimate.
After the law passed forcing insurers to accept anyone without raising premiums, Dailey was able to enroll in a Blue Cross plan in Texas, which covered his medical care that at times approached $200,000 a year. His income was low enough that he also qualified for generous federal subsidies under the law that kept his monthly premiums at no more than $235, and his out-of-pocket costs capped at around $1,000 a year.
The law has also played an important role in keeping care affordable for the 160 million Americans who get coverage from an employer, including by requiring those plans to cover the children of beneficiaries until age 26.
Before the law, employer-provided plans often set strict limits on what they would pay toward medical bills during a single year and over a lifetime. An estimated 105 million Americans had some sort of lifetime cap before the passage of the health care law.
The ACA outlawed those limits.
That has allowed Erik Westlund and Dr. Christina Cifra, of Iowa City, to afford their 4-year-old son’s care. He has hemophilia and needs a clotting factor that costs roughly $26,000 a month, or $312,000 a year. They are insured, through Christina Cifra’s job, but his more than $1.2 million in medical bills to date would have easily surpassed many employers’ lifetime caps before the ACA.
Because such limits are no longer allowed, the family doesn’t have to worry about medical expenses. “We haven’t had any financial challenges, really,” Erik Westlund said.
Still, health care remains unaffordable for many middle-class people, who don’t qualify for Medicaid or federal subsidies to help buy an individual policy.
The average premium for a midlevel plan for a 40-year-old who doesn’t qualify for a subsidy has climbed to $462 a month in 2020 from $273 in 2014, according to the Kaiser Family Foundation. And the law has done little to address soaring prescription drug costs and staggering deductibles.
“The affordability problem is different from the coverage problem,” said Katherine Hempstead, a senior policy adviser for the Robert Wood Johnson Foundation. “Health care has just become so expensive,” Hempstead said.
It’s saved lives.
Before the law passed, researchers weren’t sure that having health insurance actually improved people’s health. Of course it made it possible for people to use more health care services. But whether those services really mattered was an unsettled question.
A recent series of persuasive studies has made clear to researchers that Obamacare really did make people healthier.
“At this point now there is enough evidence that we can say confidently that giving people health insurance produces health impacts and positive health changes,” said Benjamin Somers, a physician and researcher at the Harvard T.H. Chan School of Public Health.
A number of small studies that compared states have suggested that expanding Medicaid programs improves health for poor Americans with various ailments: Studies have shown it reduces complications or improves longevity for people with renal disease, cardiovascular disease and heart failure, and after surgery.
Those studies were published in peer-reviewed journals, but they had measurement challenges that caused some scholars to view their conclusions with skepticism.
But, more recently, bigger studies with better data have answered the question more definitively.
“If you put all of it together, it seems like the ACA did have a positive effect on health and caused a reduction in mortality,” said Craig Garthwaite, a health economist at the Kellogg School at Northwestern, who had counted himself a skeptic before seeing the recent results.
The first big study looked at what happened to older low-income adults. It showed that those who lived in states that chose to expand Medicaid coverage were less likely to die than people with similar demographic characteristics in states that chose not to expand.
The second study used an even stronger methodology. Employees at the Treasury Department used tax records to identify Americans who were uninsured, then mailed a letter about health insurance options to a random sample of them. Researchers found less insurance and more deaths in the group that didn’t get a letter. Because that study cut across every state, and because the experiment used a random method of selection, several scholars who had previously been unsure say they are now convinced that the law’s expanded health insurance coverage is making a meaningful difference in physical health.
The new mortality studies measure only death rates. They don’t track the medical care or the health status of the people in the studies, so it’s still unclear precisely how that health insurance matters.
After all, even people without health insurance can go to an emergency room and receive treatment for their most acute problems. And existing networks of free and low-cost clinics have always helped some uninsured people get less urgent care.
One theory is that health insurance makes it easier to get prescription drugs, particularly drugs shown to reduce deaths from cardiac problems. A study from Somers and his co-authors found that Medicaid expansion led to big increases in prescriptions for this class of drugs.
Another theory is that, even though uninsured people can use the emergency room, insured people are still quicker to seek care there. The difference between waiting hours or days to seek care after showing signs of a heart attack or a stroke could be the difference between life and death.
Jacob Goldin, an associate professor at Stanford, who was one of the authors of the Treasury paper, said he had been surprised by how quickly his paper showed changes from health insurance. They started being able to measure reductions in deaths after just one year, he said, a timeline that may be explained by the emergency room theory.
It’s made insurers richer.
The health care industry supported the law a decade ago because it offered them tens of millions more in paying customers. “These guys supported the ACA for very good and very self-interested reasons,” said Dr. Len Nichols, a health policy professor at George Mason University.
In the early years though, it wasn’t clear that the insurance market created under the law was going to work. Healthcare.gov, the federal online marketplace, got off to a shaky start, with technical issues keeping people from enrolling in plans. Insurers also had difficulty pricing their plans. After decades of carefully selecting whom they insured, insurers were forced to operate under the new requirement to offer anyone a policy, even if that person had a potentially expensive medical condition, without charging a much higher price.
Many insurers suffered heavy losses at first. Some of the biggest players in health insurance abandoned the market. UnitedHealth Group, one of the nation’s largest insurers, bowed out in 2016, citing losses of $1 billion. Lawmakers worried about so-called bare counties, places where insurers would simply refuse to offer coverage because there weren’t enough customers or prices were too high to stay in business.
But while the learning curve was steep, insurers discovered how to prosper. They raised premiums enough to make money and narrowed their networks of hospitals and doctors to reduce their costs. Insurers also latched on to the government’s Medicaid program, which is run by private insurers in most states.
“The individual market remains profitable and stable,” concluded a recent analysis by the Kaiser Family Foundation, which tracked the financial performance of the insurers. Companies, which were once spending nearly every cent of each dollar they collected in premiums on medical claims, were now taking in enough money to have 25 cents left over in the most recent period of 2019.
Here’s its biggest flaw.
When the Affordable Care Act’s architects think about what they wish they had done differently, they often focus on one issue: the deductibles.
Most health insurance plans have deductibles, an amount that patients need to pay before coverage kicks in. The Affordable Care Act, however, allowed insurers to set deductibles significantly higher than those typically faced by Americans who get health insurance at work.
Individual deductibles can go as high as $8,150. For families, the limit rises to $16,300.
The White House and Congress wrote those amounts into the law when they drafted it in order to keep the law’s overall price tag down. Looking back, they question that decision.
“We obviously made a huge mistake,” said Ezekiel J. Emanuel, who advised the Obama White House on health policy at the time. “We were under a lot of pressure to keep the price under a trillion dollars. That was constraining everything we did, from the size of the subsidies to what type of care could have no co-pay.”
Surveys of health law enrollees show that the deductibles are patients’ biggest struggle, more so than concerns about having enough doctors in-network or even the price of the premiums. In interviews, people with coverage through the law said they’re simultaneously grateful to have the peace of mind that comes with health insurance and frustrated that they still can’t afford to see a doctor.
“Because of my experience of being uninsured, I know that my coverage has value even if I never use it,” said Elizabeth Meyer, a contract lawyer in Chicago who has purchased health law coverage since the program began in 2014. “At the same time, any health care I want is still me paying for it on my own.”
Meyer currently buys a health plan with a $6,650 deductible. She says she now goes to the doctor less than when she was uninsured, because she can no longer ask for a discount her providers typically gave to patients lacking coverage.
Jeremy Kridel, 43, lives in the Baltimore suburbs and buys coverage for his family through the health law marketplace. A federal subsidy brings the premium he pays down to $275 a month, but the plan’s $13,000 family deductible means that the family frequently skips recommended care, including for his son who has autism.
“I feel guilty,” Kridel, a rabbi, said. “My wife has a lot of damage to cartilage in her knees, but goes as long as she can between sets of shots even when her knees hurt. We know we’re just kicking the can down the road, but we couldn’t afford surgery right now.”
Some of those who worked on the Affordable Care Act say they saw this issue coming, as they were writing the legislation.
“There was an acknowledgment at the time that affordability was likely going to be a concern,” said Frederick Isai, who worked on the law as a congressional staffer in 2009 and 2010. He is now the executive director of the nonprofit Families USA, which advocates affordable health coverage.
Some expected that the health law’s subsidies would be enhanced over time, as legislators often return to make tweaks and adjustments to major legislation. Instead, Republican legislation focused primarily on attempting to repeal the health law and replace it with something else.
The health law’s architects say there is an easy way to address the health law’s large deductibles: pass new legislation that puts more money toward subsidies. Right now, the Affordable Care Act offers premium subsidies to Americans who earn up to 400% of the poverty line, about $48,500 for an individual and $100,000 for a family of four.
Subsidies for deductibles go up only to 250% of the poverty line, meaning that families like Kridel’s are excluded.
But more generous subsidies require more government spending at a time when deficits are already ballooning.
So there’s another, harder, way to fix the Affordable Care Act deductible problem: rein in America’s high medical prices. If each doctor visit and hospital stay costs less, then insurers would be able to cover more without asking patients to pay a large share.
“The biggest problem,” said Bob Kocher, a former health policy adviser to Obama, “is that health care costs have grown relentlessly.”