When President Obama took office in 2009, the U.S. was in trouble — 50.7 million people were uninsured, the largest number in history. Mortality rates were on the rise, even as health care spending grew faster than the nation’s economy. Obama was always going to address the situation through some type of health care reform, Jason Furman, chairman of the president’s Council of Economic Advisers, said recently. As the number of days left in Obama’s presidency approaches single digits, it’s clear that part of his legacy will be that his administration implemented the biggest health care overhaul since the creation of Medicaid and Medicare. What’s less clear is how those changes will be viewed years from now — and part of that depends on what happens next.
Republicans have tried to repeal the Affordable Care Act dozens of times since the law was pushed through Congress in 2010 without any support from GOP lawmakers. The party has pledged to immediately repeal the law (or, more likely, defund it) as the new session of Congress opens today, though they will likely delay the effects of the repeal and don’t yet have a replacement in place. When they do take action, lawmakers will have to contend with the massive changes the health system has already undergone as a result of Obama’s health care bill.
But understanding what changed in the U.S. under the ACA is no simple feat. We have plenty of numbers, sure, but part of the trouble is that assessing health care policy is a largely ideological affair — there are always winners and losers, and the trade-offs that seem reasonable to one group can look disastrous to another. And how Obama’s signature health legislation is viewed decades down the line will likely be informed as much by what happens next as what has happened so far. Still, a good place to start assessing the program’s likely legacy is by examining three metrics often used to judge health policy: coverage, cost and quality.
More people are insured
The ACA increased insurance coverage everywhere, among every demographic group, but just a quarter of the population knows that the uninsured rate is now at an all-time low. About 20 million people gained insurance as a direct result of the law, according to the Department of Health and Human Services.
But while the country has seen net gains in coverage, it has been a bumpy road for some. The group of people who are newly covered under the ACA includes about 16 million low-income people who gained Medicaid, which was expanded under the law to cover anyone with an income that is less than 138 percent of the federal poverty line. Not everyone in that group is now eligible for Medicaid, however. After a Supreme Court decision determined that states could decide whether to expand the program, 19 states opted not to, creating a deep geographical divide among low-income people. About 2.5 million people fall in this “coverage gap”: They live in a state that didn’t expand Medicaid, and their incomes are too low for them for them to qualify for federal subsidies in the ACA-created insurance marketplaces where people can buy private insurance.
Critics warned that the law, which required large employers to offer insurance to employees who worked a certain number of hours, would be a job-killer. They were also concerned that it would push people off of work-based insurance by leading employers to cut hours below the threshold where offering insurance was mandatory. While those doomsday predictions didn’t come to pass, it does appear that some employers limited the hours of workers who were already part-time.
For those part-timers and others, the process of buying insurance became easier with the advent of the insurance marketplaces, which allow people to compare plans. Still, of the 5 percent of Americans who bought plans outside an employer or a government program before the law passed, millions had their policies canceled, despite the Obama administration’s infamous promise that people who liked their health care plans could keep them. Those losses were partly the result of insurers phasing out plans that didn’t meet the new federal requirements for coverage — requirements that are controversial, because while they mean more comprehensive coverage, they can also mean higher premiums, which can be a turn-off for the young, healthy adults who are needed to balance out insurance pools. The Congressional Budget Office, a nonpartisan analysis arm of Congress, recently explained that at least some of the old, less-comprehensive plans would not count as insurance coverage because they don’t offer sufficient financial protection.
Among those who gained insurance were people with pre-existing health conditions. Before the ACA, insurance companies could choose to deny coverage to people on the private market, and they often did so for people who had diseases that are expensive to treat. The new law banned that practice. The Kaiser Family Foundation, which researches health care policy, recently estimated that 27 percent of adults younger than 65 would be uninsurable and that millions more could be denied coverage for specific health issues under pre-ACA, private-market norms. While many of those people have insurance through an employer or public program, they would previously have been left without options if they were to lose that insurance.
Despite challenges relating to cost and market participation from insurers, the insurance markets set up by the ACA are gaining steam. Approximately 6.4 million people have signed up for 2017 insurance coverage through the federally run marketplaces (even more have signed up on the state-run exchanges; 2017 numbers aren’t yet available, but more than 12.6 million selected a plan during the open enrollment period for 2016). That’s a record number, even as premiums increase by double-digit percentages in many places. About 85 percent of those people will receive federal subsidies that help offset the rising prices, but middle-class buyers can easily pay more than $1,000 per month.
But although the specifics of how people are covered have been shifting, the absolute increase in the percentage of people with health insurance is the blinking red data point that legislators will have to reckon with as they gear up to change, eliminate or replace the ACA under President-elect Donald Trump’s administration. Polls suggest that a growing number of people want to see the law scaled back, not repealed, and however unpopular the ACA is, taking away newly acquired insurance is likely to be controversial. Topher Spiro, vice president of health policy at the liberal think tank Center for American Progress, helped write the law. He said he thinks that because so many people are now insured, expectations regarding access to insurance have changed, which will lead to increased insurance coverage being part of Obama’s legacy, even though the GOP has pledged to repeal or defund the health care bill. “There’s no doubt in my mind that in the long term, there will be many more people insured as a result of the Affordable Care Act,” Spiro said. It’s impossible to know if he’s right, but the trepidation that some Republican legislators have recently expressed about repealing the law without a replacement plan in place suggests that he might be.