President Barack Obama signed the Patient Protection and Affordable Care Act on March 23, 2010, and so-called “Obamacare” was born. The law aimed to reform the U.S. healthcare system by expanding access to care through regulation of the health insurance industry.
Since its signing, the gradually implemented and undeniably divisive law has undergone a few changes and faced countless obstacles. Supporters hope it will rescue what they consider a broken, unnecessarily expensive healthcare system that blocks the poorest Americans from receiving needed care. Opponents think the law is poorly written and borders on Socialism. Healthcare policy experts fall somewhere in between.
“The Affordable Care Act has made a huge difference for millions of Americans,” said Benjamin Sommers, a health economist and physician who works in Harvard's Department of Health and Policy Management. “But there are things that need to be improved upon, as with any complex law.”
Read on to find out what the experts say the Affordable Care Act gets right, and what needs to be fixed. Here are several of the pros and cons of Obamacare.
5 Things the Affordable Care Act Got Right
Although widely reviled in some circles, the Affordable Care Act has helped many Americans who were left behind under the former health insurance system, health policy experts said. Here are several ways experts say Obamacare has helped.
1. More Americans Have Health Insurance
Since 2010, when the Affordable Care Act became law, 20 million uninsured Americans have gained health insurance, according to the U.S. Department of Health and Human Services.
“Roughly 20 million more Americans have health insurance now due to the ACA, giving them better access to needed medical care and helping them afford their medical bills,” Sommers said. “This is a big deal in improving people’s lives.”
2. Healthcare Is More Affordable for the Lowest-Income Americans
Although some newly insured Americans gained employer-covered health insurance thanks to a recovering national economy, according to the U.S. Census Bureau, most of the gains happened through Medicaid, which expanded under the Affordable Care Act. That means more of the country’s poorest residents are insured because of the Affordable Care Act, said Timothy Jost, a professor at Washington and Lee University School of Law and an expert on healthcare law.
“It was designed intentionally and wisely to leave health insurance alone for a vast number of Americans — so for most, it hasn’t had much effect on them," Jost said. "But particularly for people at the lower end of the economic scale, healthcare has become more affordable.”
3. Fewer Americans Have Medical Debt
Because the healthcare law covers more lower-income people who otherwise might not have insurance when a medical issue arises, medical debt has become less of an issue for many Americans, Jost said.
It’s not just medical debt that’s gone down, according to a 2016 paper by the National Bureau of Economic Research. Because lower-income people aren’t accruing as much medical debt, they’re also better able to pay other bills, the study found.
“Our main finding is that Medicaid expansions that began in 2014 significantly reduced the number of unpaid non-medical bills and the amount of non-medical debt sent to third-party collection agencies among people living in zip codes that are most likely affected by the expansions,” NBER researchers said.
4. Many Preventive Services Are Free
Although preventive services haven’t been free for many Americans for very long, Jost expects that to be an economic and health-related boon as more people are screened early. And thanks to the law, the number of people getting annual wellness visits and other preventive care “has dramatically expanded,” Jost said.
Preventive services for adults covered under the Affordable Care Act include screenings for blood pressure, cholesterol, certain types of cancers, depression, diabetes and HIV, as well as immunizations, tests for sexually transmitted infections and some contraceptives.
5. Associated Healthcare Costs Are Declining
Expenditures on public healthcare have “markedly slowed” since the implementation of the ACA, according to a report written for public policy research institute Century Foundation by Jost and fellow academic Harold Pollack of University of Chicago's School of Public Health Sciences.
Expected growth of Medicare costs has fallen below projections by billions of dollars. In states that embraced the Affordable Care Act’s Medicaid expansion, spending growth has also been restrained.
5 Things the Affordable Care Act Hasn’t Gotten Right Yet
Like any complex law, the Affordable Care Act could stand to be improved in several ways, according to health policy experts. Here are several problems with Obamacare that need to be fixed.
1. Fewer Americans Than Anticipated Have Health Insurance
Despite its success in getting millions of Americans covered, the Affordable Care Act hasn’t succeeded in getting as many people covered as its supporters originally hoped. According to the Census Bureau, 33 million Americans were still uninsured as of its 2014 survey. “Many of them are eligible for subsidized health insurance under the ACA, but haven’t yet signed up,” Sommers said.
The problem is two-fold: Lack of education on the reasons behind the individual mandate included in the law, and penalties that aren’t high enough when people don’t meet the individual coverage mandate, Jost said. “The hope was that the individual mandate would convince people they really needed to get health insurance, but for millions of people it hasn’t done that,” he said.
More public education and marketing is needed to fix the issue, Sommers said.
2. Premiums Are Higher for the Wealthiest and Healthiest Americans
For people in the non-group health insurance market who are healthier, younger and have higher incomes, premiums have gone up, Jost said.
“People who used to be favored by insurance companies for favorable selection because they were young and healthy now have to pay into more of a community rate, so they’re helping to support the people who are less healthy and older,” he said. “For those people, it has had a negative effect."
Some proposals to make health insurance more affordable for people on the higher end of the economic spectrum include use of fixed-dollar, age-adjusted, geography-adjusted rates, Jost said, which could make non-group health insurance more accessible to those people.
3. Fewer People Are Eligible for Medicaid Than Originally Expected
In 2012, supporters of the Affordable Care Act received a huge disappointment in the form of a Supreme Court ruling. The decision in the National Federation of Independent Business v. Sebelius case made the ACA’s Medicaid expansion optional for states.
“When the law was passed, Medicaid was supposed to be expanded to low-income adults in all 50 states,” Sommers said. “But the Supreme Court ruling in 2012 left that a state option, and so far, 19 states have refused to expand — leaving more than 3 million poor Americans without any way to afford health insurance.”
Jost called it “one of the worst decisions the Supreme Court has ever made,” and said he hopes that as the holdout states realize the benefits of Medicaid expansion, they’ll enact that part of the law.
4. Technology Issues Complicate the Process
The crash of the federal and state online healthcare marketplaces in the first few months of the law’s implementation made it impossible for thousands of people to sign up for the insurance they’d been promised, and problems with the technology behind the Affordable Care Act have lingered ever since, Jost said.
“Even in recent months, they’ve had issues,” he said. “Even doing pretty obvious things to improve this system is difficult because it’s such a massive system. You can’t turn it on a dime — it’s much more complicated than people think in terms of everything the technology is trying to do.”
The United States Government Accountability Office released a report in 2015 detailing the system’s past and ongoing technology issues. The report called for better implementation of development best practices.
5. The Law Is Widely Misunderstood and Politically Divisive
Insurance companies, hospitals and pharmaceutical companies used to be blamed for upticks in healthcare costs — but now, “anything that happens that affects the affordability of healthcare, people blame it on the ACA,” Jost said. In fact, he said, nothing in modern history has taken the political beating that’s been a hallmark of so-called Obamacare.
“It’s just been lawsuit after lawsuit after lawsuit — if you count contraceptive lawsuits, the administration has had to defend well over 100 lawsuits,” Jost said. “It’s absolutely unprecedented — more than 60 attempts to repeal it, a hundred lawsuits and it just never ends.”
Sommers agreed, saying the political debate about the law has been so polarized that making necessary changes is almost impossible without jeopardizing the whole system. He and Jost both blame the complexity and wide reach of the law, which make it harder for most Americans to understand.
“I’m hopeful that as the law becomes more established and after President Obama leaves office, the discussion will move from a partisan argument over ‘Obamacare’ into a more constructive discussion about how to build on the law’s successes, address its shortcomings, and improve the U.S. healthcare system,” Sommers said. “Improving our outreach efforts and continuing to educate people about how the law works are key to improving its impact.”