As the coronavirus pandemic causes Americans sky-high anxiety about their health and how they might access and afford extensive medical treatment if infected, the nation slid with only modest public attention into the second decade of one of its landmark health care experiments — the Affordable Care Act.
Obamacare became the law of the land on March 23, 2010, when the 45th president signed the 2,000-page bill for which he had campaigned long and hard. Republicans in the White House and Congress have attacked the ACA relentlessly ever since.
Researchers have spent a decade scrutinizing the ambitious act’s outcomes with zeal. The New York Times summarized some of the independent, nonpartisan evaluations, finding key areas that the public may wish to recognize in how Obamacare changed the complex U.S. health care system, on which Americans spend more than $3.5 trillion annually. In brief, as a result of the ACA, the newspaper reported (with boldface emphases mine):
- The nation saw an “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.”
- More medical treatment became available for “many who already had chronic and infectious conditions [and the act] offered preventive care to millions of people who otherwise might have become ill.
- Access improved to “coverage and care for people of color, reducing — although not eliminating — longstanding disparities.”
- Big advances occurred with a “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.”
- Affordability of medical services rose “in a number of less conspicuous ways,” with the ACA offering many Americans “the only way to get private insurance. Before the law, insurance companies were allowed to deny coverage to people … who had expensive medical conditions, or to charge such a high price that many could not afford the premiums. About half of all Americanshad such pre-existing 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.”
- Important protections were extended to keep “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.”
- Americans have become healthier, with a “number of small studies that compared states [suggesting] 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 diseaseand 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. 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 ACA’s downsides also have become clearer: Its initial coverage gains are decaying, notably with potentially damaging consequences with rises in the numbers of uninsured kids. The act for too many Americans has failed to dent ever-rising “premiums, deductibles and other out-of-pocket costs [that] continue to be an extraordinary burden on millions of households,” the newspaper reported.
After struggling with Obamacare, insurers have flourished, and, they have become richer and more powerful in ways that may not always benefit patients, including by limiting provider choices with so-called narrow networks and payments only to providers in them. The ACA has experienced what the New York Times deemed to be one of its biggest challenges in seeking to keep premiums affordable for policies offered on public exchanges by allowing sizable deductibles — and those have blown up in the years since the act’s passage. As the newspaper reported:
“The Affordable Care Act … allowed insurers to set deductibles significantly higher than those typically faced by Americans who get health insurance at work. Individual deductibles [now] can go as high as $8,150. For families, the limit rises to $16,300.”
The unending GOP attacks
That’s not good. It also has not helped that the partisan onslaught against Obamacare continues, with GOP state attorneys general, joined by the Trump Administration’s Justice Department, arguing in a lawsuit that has gone to appellate courts already that judges need to scrap Obamacare because it no longer carries a requirement for all Americans to carry health coverage or pay a special tax. An extreme legal argument asserts that without that individual mandate and a tax component, the ACA is an unconstitutional exercise of congressional authority.
A federal judge in Texas has bought into this dubious view, and an appellate court went part way with him, before telling him to reconsider in detail what parts of the ACA need to fail without the individual mandate. The U.S. Supreme Court, accepting pleas from Democratic state attorneys general, has intervened and agreed to consider the issue, with arguments possible in the fall but no decision likely until after the November elections.
President Trump, in comments in a Covid-19 news conference, “defended his continued support of the GOP lawsuit that could result in 20 million Americans losing health insurance,” the news site Politico reported. “He offered vague assurances that Republicans would support insurance protections for pre-existing conditions, though the party’s previous health proposals would weaken those provided in Obamacare. ‘What we want to do is get rid of the bad health care and put in a great health care,’ Trump said.”
What a pandemic shows about ACA’s role
As Politico and other media also have noted, however, Trump and other Republicans may find themselves relying more and more on the ACA as the nation battles the coronavirus, huge job losses, and Americans’ dire needs for affordable health care.
In its own way, Obamacare also laid crucial groundwork for how the United States will respond to the pandemic. That’s because the act and the ferocious battles over it forced Americans already to reckon with important health care fundamentals, including that health care is a right and not a privilege for an elite few. The ACA also plunged the public into a long and raging argument over basic ideas in insurance, especially health coverage — the sharing of risks, costs, harms, and benefits.
The ACA has become more popular than ever, particularly as patients have embraced the myriad ways it reshaped the health care system as well as insurance coverage. If Obamacare, indeed, has gotten people to understand the importance of collective altruism to U.S. society and its function, this, for example, could buttress public health experts’ campaigns to get Americans to protect the collective wellness by hunkering down to “bend the curve” and not only reduce viral infections but also to keep them from overwhelming the nation’s health care system.
In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent health care. This has become an ordeal, even with the ACA, due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs.
Obamacare is far from perfect, and, especially a decade in, its accomplishments could be burnished by key adjustments that lawmakers could undertake to benefit the American people. Let’s see if the partisans try to send a health care initiative that has done much good to the junk heap of history — either because some, on the left, dream of the nation having a much-desired but hard to put in place single payer system, or because those on the right, almost theological in their opposition, keep trying to kill the ACA because they want government in no part of health care.
The pandemic-caused pandemonium may so overwhelming now that it may be difficult for all of us to look, with optimism and duty, to the momentous elections in November. The president, his people, and his party have their hands full in protecting the nation from the coronavirus. Soon, voters will judge them on their performance with this immense task, as well as with their record on health care altogether, including their staunch opposition to the ACA and their failure after a decade to propose a better option.