10 Years of the Affordable Care Act – An important tool in the COVID response

By Suzanne Wikle

Ten years ago today, Congress passed the Affordable Care Act (ACA), the most remarkable and important health policy changes since the creation of Medicare and Medicaid in 1965. Between 2010 and 2018 (latest data available), nearly 20 million more Americans gained health insurance. The bulk of this enrollment is due to the ACA’s provision on Medicaid expansion, which targets adults with incomes under 138 percent of poverty. More than 400 studies have shown that expanded health insurance coverage is associated with improved access to care, more affordability, better financial security, increased personal health, and healthier state economies.

The COVID-19 pandemic has highlighted the importance of health care for economic and physical wellbeing. The crisis also reminds us that that everyone’s health is interconnected, and the health of everybody is at risk when some of us don’t have access to insurance and affordable care. The consequences of the pandemic are disproportionately falling on individuals and families with low incomes who work paycheck to paycheck and, even in ordinary times, worry about being able to access affordable health care. As hard as this is to think about – without the ACA, our current crisis would be much worse.

The ACA has been a success and shown us the next steps we should take in health reform.

Increased Coverage. By far, adults with low incomes have benefitted tremendously from the ACA due to the expansion of Medicaid. Millions more adults now have health insurance because of Medicaid expansion. However, 14 states have not yet expanded Medicaid, leaving 2.3 million adults without access to health insurance. Of those 2.3 million, 92 percent live in the South, which is one reason why people of color are more likely to be in the coverage gap. In addition to adults living with low incomes in non-expansion states, immigrants (including those who are lawfully present) are not eligible for many of the ACA’s provisions. In fact, over 4 million immigrants are ineligible for coverage. Moreover, with weakened civil rights protections, language accessibility for immigrants is not always certain.

Reduced Disparities. Several studies have found that Medicaid expansion is associated with a reduction in disparities by race/ethnicity, income, education level, insurance type, and employment status. For example, the infant mortality rate for Black babies has decreased more significantly in expansion states than in non-expansion states—and more rapidly than for white babies. Research also shows that many people of color were more likely to delay care prior to the ACA. Importantly, Hispanic and Black Americans continue to report the highest rates of forgoing care due to cost, but they have also reported the most change in this indicator. The ACA has contributed to a reduction in inequity, particularly on the rate of insurance, and evidence continues to emerge about disparities narrowing among health outcomes.

Improved Financial Security. In addition to the financial security provided by Medicaid coverage, additional ACA policies have helped Americans’ financial security. Health insurance plans can no longer place a lifetime limit on expenses, and pre-existing conditions must be covered. In the current COVID-19 pandemic this would mean that people don’t have to worry about their insurance “running out” after a certain number of days or weeks in the ICU. While there’s still more progress to be made on the affordability front, we’re certainly in a better place than a decade ago.

Thankfully, the ACA is in place. Unfortunately, it’s still facing a court challenge that stands to eliminate the law and wipe out the gains we’ve made. While this is dangerous and irresponsible during normal times, the consequences of this are magnified in the face of our current pandemic.

We should all work to make sure the successes of the ACA are known, especially during the critical time our country is now facing. As CLASP reflects on the significance of the ACA, we also look forward to the day when our country takes the next step to ensure that health care in America is deemed a human right, that we explicitly and fully address health equity, and that we address social determinants of health. That’s why CLASP has identified a set of principles for how our country should approach public policies aimed at providing health care for all to guide the looming discussions.