The Patient Protection and Affordable Care Act (ACA), signed into law by President Barack Obama in 2010, transformed the way the U.S. health care system provides health insurance coverage that curbed health care costs and modified how health care is delivered. On the 13th anniversary of the law, it’s clear that it advanced America closer toward universal coverage, but challenges remain. As lawmakers and key stakeholders address these systemic issues that contribute to more expensive, less accessible health care, it is critical that they focus on building on the law by prioritizing Medicaid expansion in non-expansion states, mitigating coverage loss from the unwinding of the public health emergency (PHE) declaration, ensuring the U.S. has the resources needed to respond to ongoing COVID-19 costs and future pandemics, boosting funding and state data infrastructure to strengthen efforts to address social determinants of health, and expanding postpartum Medicaid coverage.
The ACA has faced an obstacle-strewn path with countless legal and legislative challenges throughout the past 13 years. Only one House Republican voted for the ACA’s passage in 2010. Republicans have since been waging an implacable battle to repeal “Obamacare,” which they touted would undermine private insurance markets and raise premiums. Nearly every budget or fiscal plan of theirs since the law’s enactment has included repealing the ACA as well as cutting Medicaid. After President Donald Trump’s election, Republicans tried repeatedly to repeal and replace the ACA but failed, despite controlling both chambers of Congress. In a dramatic 2017 vote, Republicans fell one vote short of repealing the law. In the 2018 midterm elections, they lost control of the House in a Democratic sweep, attributed in part to growing public support for the ACA.
Simultaneously, the ACA has been subjected to more than 2,000 legal challenges since its implementation. The most recent notable case, California v. Texas, which was heard by the Supreme Court in June 2021, claimed that the lawsuit filed by Texas lacked standing. The Texas district court asserted that the reduction of the individual mandate in the 2017 Tax Cuts and Jobs Act to zero was justification for the ACA’s unconstitutionality as an improper use of Congress’s taxation powers. Legal experts, even those opposed to the ACA, agreed that the legal arguments to this case were absurd, as Texas ignored Congress’s decision to zero out the individual mandate but to leave the rest of the ACA in place, which is principally Congress’s decision, not the court.
Despite the at least 70 Republican attempts to repeal or modify the ACA, the law seems firmly entrenched as a permanent feature of America’s hybrid, public-private health care system. It has delivered on its promise to increase coverage and access for millions of Americans and played a key role in helping people who lost job-based insurance stay covered throughout the COVID-19 pandemic. The law also has been a milestone in the Democratic Party’s century-long struggle to create a universal health care system that leaves no one out. It’s brought our country very close to universal coverage, while also testing new ways to deliver health care and reduce its cost.
This policy brief will examine the benefits of the implementation of the ACA, how to build on the ACA’s accomplishments, and rein in high medical costs to improve community health.