Healthcare Policy

EDITORIAL

The US Affordable Care Act: Reflections and

directions at the close of a decade

Adrianna McIntyre 1 , Zirui SongID

2,3*

1 PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts, United States of America,

2 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States of

America, 3 Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States

of America

* [email protected]

Nearly nine years after its passage, the Affordable Care Act (ACA) remains at the forefront of

public policy debate. The law is persistently contentious as a matter of public opinion, but rep-

resents a historic achievement in United States healthcare reform. While it was incremental in

many respects—health insurance plans for the vast majority of Americans were relatively

unchanged—the ACA left an indelible mark on the healthcare system through its expansion of

insurance coverage and efforts to improve the healthcare delivery system. In the past decade,

the country has witnessed a substantial decline in the number of uninsured individuals, while

other elements of the law have sought to make inroads into affecting the cost and quality of

care [1]. Yet looking forward, the ACA continues to face challenges that make its abiding

impact and legacy uncertain.

What the ACA did for insurance expansion

The ACA expanded insurance coverage in two principal ways. First, it created health insurance

marketplaces at the state level on the premise of competition and choice; individuals could

compare similar coverage options and choose among competing plans. The health law also

provided low-income individuals and households up to 400% of the federal poverty line with

subsidies to help them purchase insurance. Second, the ACA expanded eligibility for the Med-

icaid program to individuals and families with incomes up to 138% of the federal poverty

line—about US$35,000 for a family of four. Since the law’s implementation in 2010, the num-

ber of uninsured people in the country has fallen by about 20 million [2].

The ACA reshaped private insurance in other important ways. It established new minimum

federal consumer protections; of note, insurers were prohibited from discriminating on the

basis of health status—they could not turn people away or charge higher premiums due to pre-

existing medical conditions. A set of 10 “essential health benefits” was defined. Annual and

lifetime limits on covered health benefits were abolished. The law’s dependent coverage provi-

sion enabled children up to age 26 to stay on their parents’ insurance, benefiting between 2

and 3 million young people [3].

Expansions in health insurance were aided by complementary policies that encouraged

people to enroll in coverage. Federal tax credits that reduced the financial burden of monthly

premiums—and, in some cases, reduced cost-sharing—made plans on the marketplaces more

appealing to low-income consumers. The subsidies functioned as a carrot that was balanced by

a stick: the ACA’s individual mandate required people to get covered or else pay a tax penalty.

However, the Tax Cuts and Jobs Act effectively eliminated this policy by lowering the penalty

for not having health insurance to US$0 beginning in 2019.

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Citation: McIntyre A, Song Z (2019) The US

Affordable Care Act: Reflections and directions at

the close of a decade. PLoS Med 16(2): e1002752.

https://doi.org/10.1371/journal.pmed.1002752

Published: February 26, 2019

Copyright: © 2019 McIntyre, Song. This is an open access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Funding: This work was supported in part by a

grant from the Office of the Director, National

Institutes of Health (NIH Director’s Early

Independence Award, 1DP5OD024564, to ZS). The

funder had no role in study design, data collection

and analysis, decision to publish, or preparation of

the manuscript.

Competing interests: I have read the journal’s

policy and the authors of this manuscript have the

following competing interests: ZS is a member of

the Editorial Board of PLOS Medicine.

Provenance: Commissioned, not externally peer

reviewed.

When it launched in 2014, this type of regulated individual market was new terrain for most

insurers. They were responsible for projecting the likely healthcare costs of people who would

elect to take up coverage, with limited experience to guide these estimates. To assuage insurers’

concerns about enrolling unexpectedly sick (and expensive) populations, the ACA implemented

federal protections through three programs: risk corridors, reinsurance, and risk adjustment. The

first two were temporary; they expired after three years but gave insurers an opportunity to find

their footing and price their products accurately. Risk adjustment is a permanent program,

intended to mitigate against insurers selecting healthier enrollees and avoiding sicker populations.

Challenges to the ACA

The law has endured numerous legislative challenges following its passage. The House of Rep-

resentatives advanced over 50 bills to repeal the ACA in whole or in part, with the Senate vot-

ing on a subset of them [4]. These started out as largely symbolic—a presidential veto was

virtually guaranteed while President Obama was in office—but began to pose an existential

threat to the ACA under a unified Republican government that held power during the first

two years of the Trump administration. The narrow 49-to-51 vote defeat of the last prominent

repeal effort in the summer of 2017 illustrated the tenuous grounds upon which the law sat in

the previous Congress. However, its survival was also a testament to its legislative durability;

the political challenge of withdrawing health benefits shared across different constituencies

has thus far been insurmountable, despite lukewarm public opinion on the law.

Proponents of the ACA have identified some regulatory actions by the Trump administra-

tion as unilateral efforts to undermine the law. For example, terminating funding for cost-

sharing reductions, which are supplemental subsidies available to some low-income enrollees,

led to fears about destabilizing the markets and increasing the ranks of the uninsured. Cutting

resources allocated to enrollment outreach and education have raised similar concerns. Recent

changes to insurance regulations will likely make plans that bypass the ACA’s consumer pro-

tections more common. Moreover, the administration has made it easier for states to modify

their Medicaid programs in ways that could lower enrollment (by requiring nondisabled bene-

ficiaries to work in order to qualify for benefits, for example). Its proponents have championed

these changes as efforts to promote consumer choice and state innovation.

Other serious threats to the law’s sustainability have come from the courts. A landmark

2012 Supreme Court decision scaled back the Medicaid expansion from a nationwide mandate

to a state option. To date, 14 states have declined to expand their Medicaid programs (although

this number has gradually decreased in recent years). Another challenge sought to roll back

subsidies on the ACA marketplaces. Still other litigation concerning regulations related to con-

traceptive coverage is ongoing. Perhaps the ACA’s greatest lingering existential threat comes

from a late-2018 district court ruling in Texas. The judge in this case ruled that the zeroed-out

mandate is unconstitutional—and, moreover, that the mandate is not severable from the rest

of the ACA, meaning that the rest of the law would need to fall with it. The case is now within

the appeals process and could end up before the Supreme Court.

Looking forward: 2019 and beyond

The prospects for near-term repeal have diminished with Democrats taking control of the

House of Representatives, but the ACA has not receded from the public debate. On the con-

trary, healthcare ranked among voters’ most important issues in the 2018 midterms. The

administration and new Congress will need to decide whether to leave the law alone or modify

it. Additionally, attempts to weaken the law through regulatory channels will be subject to

increased scrutiny now that Democrats have more congressional oversight.

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002752 February 26, 2019 2 / 3

Opportunities for bipartisan legislation to stabilize the law appear slim. The leading Repub-

lican and Democrat of the Senate Health, Education, Labor, and Pensions Committee coau-

thored a modest marketplace stabilization bill in 2017 that would have provided funding for

cost-sharing reductions, increased funding for enrollment outreach and assistance, and made

other minor tweaks to the law. However, Democrats may be reticent to revive that bill, as

insurers in many states addressed the cost-sharing reductions issue in a way that made insur-

ance more affordable for subsidized enrollees. A more ambitious stabilization bill was intro-

duced by House Democrats in 2018, which would increase the availability of marketplace

subsidies by lifting the income cap (currently at 400% of poverty), reverse certain regulations

by the current administration, and provide more funding for consumer outreach and assis-

tance. The prospects of this bill are dim without support from across the political aisle.

Perhaps more fundamental for the future direction of health policy, public opinion on the

role of government in healthcare is evolving. In 2013, 42% of Americans believed that it is the

responsibility of the government to ensure that all Americans have coverage; that number rose

to 60% in 2017 [5]. Support for “Medicare for All” proposals has also climbed in recent sur-

veys, though these opinions have been malleable to follow-up questions. These public opinion

trends suggest that a growing share of Americans may be receptive to proposals that move the

ACA in a more progressive direction.

References 1. Blumenthal D., Collins S. Health Care Coverage under the Affordable Care Act—A Progress Report. N

Engl J Med. 2014 July 17; 371(3):275–281. https://doi.org/10.1056/NEJMhpr1405667 PMID:

24988300

2. Martinez M., Zammitti E. and Cohen R. (2018). Health Insurance Coverage: Early Release of Estimates

From the National Health Interview Survey, January–June 2018. National Health Interview Survey Early

Release Program. [online] Division of Health Interview Statistics, National Center for Health Statistics.

Available from: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201811.pdf [Accessed 17 Jan.

2019].

3. Uberoi N., Finegold K. and Gee E. (2016). Health Insurance Coverage and the Affordable Care Act,

2010–2016. [online] Washington, DC: Department of Health and Human Services, Office of the Assis-

tant Secretary for Planning and Evaluation. Available from: https://aspe.hhs.gov/system/files/pdf/

187551/ACA2010-2016.pdf [Accessed 17 Jan. 2019].

4. O’Keefe E. (2014). The House has voted 54 times in four years on Obamacare. Here’s the full list. The

Washington Post. [online] Available from: https://www.washingtonpost.com/news/the-fix/wp/2014/03/

21/the-house-has-voted-54-times-in-four-years-on-obamacare-heres-the-full-list/ [Accessed 20 Jan.

2019].

5. Blendon RJ, Benson JM. Public Opinion about the Future of the Affordable Care Act. N Engl J Med.

2017 Aug 31; 377(9):e12. https://doi.org/10.1056/NEJMsr1710032 PMID: 28813210

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