10 years on, ACA faces an uncertain political future

It's hard to believe that the Affordable Care Act (ACA) turned 10 on March 23, 2020, marking a decade since President Obama signed the bill into law.

As with any milestone anniversary, it's timely to reflect on how the ACA came of age, ACP's role in getting it passed, what it has and hasn't accomplished, how it's survived despite sustained political and implementation challenges—and what the future holds for it.

ACP's role in the ACA becoming law

ACP played a major role in shaping the ACA and getting it passed. We shared our ideas on what should be included in the bill with White House staffers and Congress, and when we found that the bill largely reflected our recommendations, we came out strongly in support of it. We were there for all the ups and downs preceding the ACA's enactment. There were times when it seemed like it would never become law because of uniform Republican opposition and dissension within the Democratic ranks.

Yet like so many others, ACP celebrated on March 21, 2010, when the final bill passed both the House and the Senate, and two days later, when President Obama signed the ACA into law. The law wasn't perfect, for sure, and the highly partisan and polarized politics around its enactment were regrettable.

Yet ACP supported the ACA because we believed that it had the potential to greatly increase the numbers of Americans with health insurance coverage while providing protections for hundreds of millions more by banning insurers from discriminating against people with pre-existing conditions, ending lifetime or annual limits on coverage, and requiring all insurers to cover essential medical care.

What has the ACA accomplished?

Ten years on, we can see that the ACA largely lived up to its potential while falling short in some respects. Tens of millions of Americans who in the past would have gone uninsured have gained coverage, either through Medicaid in the states that have expanded it or through subsidized private insurance. No one can be turned down or charged more for a pre-existing condition. Lifetime and annual coverage limits are gone. Public support for the ACA is at an all-time high, according to recent polls.

Yet the law has not fully lived up to expectations, due in large part to court rulings, sustained political opposition from some quarters, and implementation problems. On July 28, 2012, the Supreme Court upheld the constitutionality of the ACA's individual insurance mandate, but with a hitch, ruling that the federal government couldn't coerce states into expanding Medicaid to all low-income persons by withholding federal funds. As a result, many Republican-controlled states refused to expand Medicaid, leaving millions of poor people who were originally expected to be covered by Medicaid without coverage.

Public confidence was undermined, to put it mildly, by the botched launch of the www.healthcare.gov website in October 2013. It took months before people could seamlessly enroll. In many insurance markets, people found limited insurance choices available to them, often with high deductibles and narrow clinician networks.

The ACA has also had to weather continued political opposition. It barely survived after President Trump was elected and the GOP took control of both the House and the Senate in 2016-2017, largely on a platform of repealing “Obamacare.” Yet the Republicans were unable to find the votes they needed in their own ranks to get “repeal and replace” legislation through the Senate.

Instead, the Trump administration has used its regulatory authority to undermine many of the ACA's protections, allowing “short-term” plans to be sold that don't have to cover necessary medical care, seeking to impose work requirements for Medicaid, and proposing that states be allowed to partially convert Medicaid to a block grant program. (Medicaid work requirements and block grants are being challenged in the courts.)

An uncertain future

The ACA faces continued legal challenges. On March 1, the Supreme Court announced it would rule later this year on a lawsuit brought by 20 GOP-controlled states that could strike down the entire law, strike down part of it while leaving much of the ACA intact, or uphold all or most of the ACA. There is no realistic plan for Congress to pass a bipartisan replacement this year should the Supreme Court overturn the ACA.

While continued GOP opposition might be expected, the ACA is also facing challenges from some Democrats. Among the Democratic presidential candidates, Sen. Bernie Sanders (D-VT) seeks to replace all private insurance with a single-payer, Medicare-for-All plan, ending the highly regulated and subsidized private insurance marketplaces created by the ACA. Former Vice President Joe Biden proposes to keep and improve on the ACA while creating an option for Americans to enroll in a plan based on Medicare.

ACP, for its part, believes that there is much that should be done to improve the ACA. Yet we too believe it's time to look beyond it and transition to true universal coverage through a public option or a single-payer system, as outlined in ACP's Vision for the U.S. Health Care System.

These are not contradictory goals. By advocating for improvements to the ACA and opposing efforts to undermine it, ACP is offering a way to help more people get affordable coverage under the current system. By advocating for comprehensive solutions that would ensure all Americans have coverage, either through a single-payer system or a public option, ACP is offering a vision of a better health care system that goes beyond the ACA.

Just as we proudly did a decade ago when we championed a law that took us part of the way to affordable coverage for all, ACP looks forward to the day when we can look back with pride at our contributions to enacting a national health care program where everyone will have good coverage, without regard to their health or employment status, place of residence, or income. In the meantime, we'll continue to advocate to preserve and improve the ACA as an essential step toward this goal.