WASHINGTON -- As the nation battles COVID-19, the health policy world is quietly observing a milestone: the 10th anniversary of the Affordable Care Act (ACA).
As he was signing the bill into law on March 23, 2010, , "The bill I'm signing will set in motion reforms that generations of Americans have fought for and marched for and hungered to see." He listed some of the bill's provisions, including a ban on insurer discrimination against enrollees with preexisting conditions, a mandate to cover children up to age 26 on their parents' policies, and a requirement that all health insurance policies cover 10 categories of "essential health benefits."
The law also strongly encouraged states to expand their Medicaid programs to include able-bodied adults making up to 138% of the federal poverty level -- failure to do so would result in a state losing its federal Medicaid match -- and created health insurance marketplaces in which individuals and small businesses could shop for health insurance plans. (The Medicaid expansion provision was later changed as a result of a Supreme Court case and is now completely optional for states.)
One Thing's for Sure...
Analysts looking back at the law all agree on one thing: it did increase the insurance rolls -- "primarily through Medicaid," said Bob Moffit, PhD, senior fellow in health policy studies at the Heritage Foundation, a right-leaning think tank here. "Roughly 90% of new coverage came out of Medicaid. And there's no question it increased access to healthcare, particular mental health benefits and services for low-income people," as well as reducing uncompensated care costs.
Currently, the percentage of uninsured Americans stands at 9.1%, down from 16% when the law was signed into effect, Rosemarie Day, CEO of Day Health Strategies in Somerville, Massachusetts, and the author of , noted in a . However, although the ACA made these gains possible, there are still many uninsured and underinsured patients who likely would be afraid to seek care if they thought they had COVID-19, because they might not be able to pay for it, Day said in a phone interview.
"We don't have a culture of universal healthcare; we have a culture of 'Gotcha,'" she said. "You show up in the ER? Here's a bill. People are afraid of that if they don't have the resources ... Also right now, immigrants are going to be very afraid because they're told they're going to be deported if they use anything that's publicly funded," such as Medicaid.
On the other hand, the ACA has done a lot to help people get care earlier for other types of illnesses, including preventive care, which is one of the ACA's essential health benefit categories. "Many preventive services are free, so people are availing themselves and therefore getting tested earlier than they would, meaning that if perchance you have cancer, you're getting screened earlier in the game," Day said. "That whole flow prevents unnecessary deaths and it's all about that access to healthcare."
...But Problems Remain
But the law still has a lot of problems, said Joe Antos, PhD, scholar in healthcare and retirement policy at the American Enterprise Institute, a right-leaning think tank here. "The most obvious one is the Democrats' overreach on Medicaid," he said in a phone interview. "They wanted to make it look like states would have a choice about whether they expanded Medicaid or not. But the penalty ... goes beyond a simple penalty. They didn't have to do that."
Instead, the Obama administration "could have found some way to phase in mandatory eligibility up to where they ended up," said Antos. "In retrospect, that was a really terrible mistake. What we have now is 13 states -- mostly Southern states -- who did not expand their Medicaid eligibility under the ACA and they're in even greater trouble now than they were before. So that's a truly lost opportunity with regard to this virus pandemic, because that would have been resolved by now."
Moffit sees a different flaw with the ACA. "The problem the ACA had is that the ACA did not control costs," he said in a phone interview. "If you look back to 2010, and asked Americans what was the number one problem in the healthcare system, it was how to control healthcare costs. When President Obama was campaigning for the ACA, he made the argument that we'd see a $2,500 reduction in typical family health care costs" each year. But "that was total nonsense; it never happened," Moffit said, adding that instead premiums jumped from an average of $244 per month in 2013 to $550 per month.
Differing Solutions
Moffit has his own solution to the ACA's problems. "We ought to target the funds a lot better than in the past," he said. "I like the idea of taking all the money we're spending on the ACA -- about $1.6 trillion -- and turning it into block grants for states, on two conditions: that states offset the cost of health insurance for people who are low-income; and that states offset the cost of coverage for people with preexisting medical conditions."
He praised the ACA's provision banning discrimination against patients with preexisting conditions, adding that in order to improve the law, the federal government could "allow states to address this in different ways, whether through reinsurance pools, risk transfer pools, or direct subsidies ... there are a lot of different ways of doing that." Moffit's home state of Maryland, where he is a former member of the state's Health Care Commission, is using a 1332 waiver to establish a reinsurance program for higher-cost patients. The program "has been dramatically successful. There has been a 10% reduction in individual market premiums, so it's working out quite well," he said.
Day prefers a different approach: universal coverage using a hybrid public/private system. One way to improve coverage would be to increase enrollment among people who are eligible for government health insurance -- such as for the Children's Health Insurance Program -- but haven't yet been enrolled. "We ought to have some form of auto-enrollment for kids," she said. The federal government also should put more "guardrails" on the plans in the ACA's health insurance exchanges, "regulating the plans to include essential health benefits and do the things the private market wouldn't do on its own. That's how other countries do it," such as Germany, she said.