Public support for the ACA has increased, but there is still a partisan divide about the program.
SPRING OF 2023 MARKS THE 13TH ANNIVERSARY of the Accountable Care Act (ACA), signed into law by Barack Obama on March 23, 2010. The goals of the law were to make health insurance available to more people, expand the Medicaid program, and undertake initiatives to lower health care costs and improve quality.
Through the ACA, the number of Americans without insurance dropped by approximately 20 million. Enrollment in private health care plans through government-sponsored marketplaces reached a record high of 14.5 million. Here’s what’s new with the Affordable Care Act.
Expansion of Medicaid
The aca allowed states to expand Medicaid eligibility to those with incomes at 138% of the federal poverty level, with the federal government picking up almost all of the added cost. (In 2022 in the 48 contiguous states, 138% of the poverty level was $18,754 for a single person and $38,295 for a family of four.)
As of 2022, 38 states and the District of Columbia accepted the expanded Medicaid program, with Missouri and Oklahoma joining within the last 18 months. Twelve states, mostly in the South, declined to expand their Medicaid programs.
Increased subsidies for health insurance
The American Rescue Plan Act, enacted during the pandemic, increased subsidies for purchase of insurance. Prior to the act, eligibility for subsidies was capped at400% of the federal poverty level ($54,360 for a single person and $111,000 for a family of four).
Under the Recuse Plan Act, a person was eligible for subsidies if that person spent more than 8.5% of his or her income on insurance. According to an analysis by the Kaiser Family Foundation, this had the effect of making approximately 3.7 million more people eligible for subsidies, including some with incomes more than 400% of the poverty level. People with income significantly above 400 percent of the poverty level would not likely receive subsidies since they usually would not spend more than 8.5% of their income on insurance.
The increased subsidies were part of a two-year plan, which was scheduled to expire at the end of 2022. In August of 2022, President Biden signed the Inflation Reduction Act, which, among other things, extended the subsidies until the end of 2025
Fixing the “family glitch”
When making changes to the aca by statute or regulation, lawmakers will seek to fix what is known as the “family glitch.” Under current law, an employee’s eligibility for subsidies is determined by the cost of insurance for the employee only — not for the cost of the employee obtaining insurance for his or her family.
The cost of family coverage, of course, is a great deal more than individual coverage. For moderate income families, individual insurance may be affordable, but family coverage may not be. The potential reform would make the 8.5% eligibility criteria apply to family coverage as well as individual coverage.
ACA cases to the Supreme Court
The aca has been challenged repeatedly, particularly by Republicans, with three cases ruled upon by the u.s. Supreme Court.
The aca withstood the main challenges. In 2012, the Court by a 5-4 vote upheld most of the act, including the mandate that individuals acquire health insurance. The Court held that the mandate was a valid exercise of Congress’s taxing power.
The Court, however, struck down a provision in the law by which Congress would have withheld all Medicaid funds — including for existing Medicaid beneficiaries — from states that refused to expand their Medicaid programs. The Court said that Congress through its spending power can encourage states to take certain actions, but withholding all Medicaid funds was unduly coercive.
As a result of the ruling, 12 states were able to decline to expand their Medicaid programs.
Public opinion toward ACA
Public opinion toward the aca has improved in the last five years. According to a Kaiser Family Foundation Health Tracking Poll, 55% of the public now holds a favorable opinion of the aca compared to 42% with a negative opinion.
Nonetheless, some aspects of the aca are popular with a majority of people. Up to 72% of all respondents said it is “very important” to keep in place protection for people with pre-existing conditions (with the precise percent varying with which protection is being considered).
Impact on physicians
The increase in coverage provided by the aca has helped physicians and other health care providers because more people have insurance through which they can seek care and pay their bills. On the other hand, to the extent that insurance through aca (as well as traditional private insurance) have high deductibles or other co-pays, that may result in difficulty for providers being able to collect payments.
The reimbursement rates of marketplace and Medicaid plans often are less than traditional private insurance. The American Medical Association has commented,“Physician payments under any public option must be higher than prevailing Medicare rates and at rates sufficient to sustain the costs of medical practice.” •
JEFF ATKINSON (JAtkin747@aol.com) is a professor for the Illinois Judicial Conference and has taught health care law at DePaul University College of Law in Chicago
Key elements of the ACA
Making health insurance available through public exchanges or marketplaces
Reducing cost of private insurance through tax credits (the American Rescue Plan Act of 2021 increased the amount of subsidies, and the Inflation Reduction Act extended subsidiesuntil the end of 2025)
Preventing discrimination in insurance on the basis of pre-existing conditions
Eliminating lifetime limits on insurance coverage
Allowing young adults to remain on their parents’ health plans until age 26
Increasing coverage for preventive services, mental health services and prescription drugs
Increasing utilization of payment methods based on quality of care