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For decades, U.S. legislators struggled with how to ensure all Americans had health insurance. Every other developed country – and many less developed – had some kind of universal or near-universal coverage. On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act, commonly shortened to Affordable Care Act (ACA) or “Obamacare.” At the time, it was forecast to cover about 32 million Americans by 2019, a forecast that has gradually dropped amid barriers to implementation and persistent political opposition. The complex, multi-part legislation remains highly divisive and misunderstood. Political and policy uncertainties have shadowed, threatened and changed implementation. It is likely to remain controversial through the 2016 presidential election – and beyond. A Republican president in 2017 is likely to seek to repeal the law, or at least make fundamental and significant changes to decrease its size and scope.

The law has withstood two major Supreme Court challenges. The court in 2012 upheld its constitutionality – but ruled that the Medicaid expansion was optional for the states. As of early 2016, 19 states have still not expanded Medicaid, and very few show any movement toward changing that this year. The second Supreme Court case, King v. Burwell, challenged a core provision – the insurance subsidies for millions of Americans getting covered through HealthCare.gov – but in June 2015 the court upheld the subsidies. That’s likely the last major legal challenge to central tenets of the law. But it did not quell the political opposition – as the “Repeal and Replace” pledges in the 2016 presidential contest illustrate.

The difference between states that have expanded Medicaid and those that have not has become sharper, both in terms of coverage numbers, and in how hospitals are faring financially under reform. But the higher uninsurance rates in non-expansion states is one reason the Congressional Budget Office’s forecasts for ACA coverage participation have dropped. (Another reason was better news; the CBO had thought more businesses would drop insurance and shift their workers to the exchange. That didn’t happen.) Still several national surveys have found that the uninsurance rate has been dropping steadily to about 9 percent – the lowest rate since the CDC started tracking coverage in 1972. President Obama announced in March 2016 that 20 million people have gained coverage under the ACA. There are about 30 million people still likely to be uninsured in the next few years (including undocumented immigrants who are ineligible for coverage) a decade or so after passage, remember that without the ACA, the government had projected there would have been 57 million.

Medicaid isn’t the only way that conservative states have resisted. About 2/3 of the states decided they would not or could not run all or parts of the health insurance exchanges by themselves, at least not in the first few years. That shifted the responsibility to the federal government – and the disastrous rollout of the HealthCare.gov online portal on Oct. 1, 2013. Only one state that used the federal exchange in 2014 – Idaho – decided to run its own in 2015, while four states that had set out to run their own portal but failed or gave up adopted he federal portal while they maintained control over parts of their own exchanges.

Political and pragmatic delays repeated pushed key deadlines back. One such delay was the employer mandate, which is the requirement that businesses with more than 50 workers offer affordable coverage. First, it was pushed back to 2015, and then it was delayed again to 2016 for businesses with 50 to 100 workers. It did begin to phase in on Jan. 1, 2015 for larger firms, and in 2016 it went into effect fully.  (Small firms remain exempt as originally planned. They have the option of using Small Businesses Exchanges, or SHOP, but few have. Participation in that program has fallen short of expectations, and the exchanges lagged in introducing features that may have attracted more businesses.)

The headlines and airwaves are awash in competing claims about the cost and quality of coverage under the ACA. Will the “winners” outnumber the “losers?” Who decides – and when will we know?

The politics show no sign of abating. The government may not shut down over “Obamacare” again in the near future, but expect nonstop congressional battles, oversight hearings, funding wars and campaign fodder. Republicans won control of both chambers of Congress in 2014.  They can’t repeal “Obamacare” – not while President Obama remains in the White House. But they can still hamper it.

Yet while the legal and legislative battles rage, the law has begun to work, albeit imperfectly. By early 2014, the federal website and some of the states’ enrollment sites were working much better. The rollout in 2015 and 2016 went smoothly. The White House met its 2015 coverage goals and is on track for the enrollment goals for the end of 2016 (although the targets were revised downward in 2015 – and were even more modest for 2016.) Millions more are covered in Medicaid. Some people got covered enthusiastically, while others did so because their old plan was no longer an option or because they feared a penalty. Most of the disaster scenarios – runaway premiums, overcrowded hospitals, long waits for health care, a collapsing financing system – have not come to bear, although premiums did rise more sharply in 2016 than the first two years, with a few states registering particularly high spikes. Congress in a big bipartisan budget deal in late 2015 also suspended several taxes that had helped fund the ACA, raising questions about its impact on the federal budget going forward.

Health care reform is sprawling and complex, with moving parts and unintended consequences. Health spending represents more than one-sixth of the economy –it hit $3 trillion in 2014, and the rate of growth appears to be ticking up. Health policy touches every individual, every family, every community. It is politically volatile, because it’s not only about health, or about money, but about the size and reach of government.

All of this has fueled a debate about health reform almost as intense after the law’s passage as before. Hardly a day goes by when someone in Congress isn’t threatening to repeal or defund it, or when some governor or state legislator is vowing to defy it. How can we journalists cover a story with so many tentacles, so much misconception, so much rhetoric, so much jargon, so many statistics and so many acronyms (ACO, ACA, PCORI, IPAB, CMMI, MLR, AHBE, etc.) that our heads spin?

Perhaps the first thing to understand is that most of the political fighting was – and probably will remain – about the cost of covering millions more Americans and transforming parts of the health insurance industry. That’s a gargantuan task and it’s legitimate to ask questions about the costs and consequences of coverage, such as emergency room crowding, primary care shortages, basic benefits, or affordability of the insurance policies we will be required to have (with subsidies for those who qualify.)

But health care reform isn’t only about covering more people. The law touches on just about every aspect of health care. Delivery system reform (a clunky and confusing phrase that many readers and listeners may think pertains to the fate of Saturday mail service) has the potential to change how Americans receive care, and how doctors and hospitals are paid for care. It’s about doing a better job of managing and treating chronic disease, in a system that really has its roots in acute care circa 1960. It’s about aiming to ensure that people get quality care they need. It's about changing the culture and the payment incentives so that doctors and patients alike come to understand that newer, more expensive and higher-tech care isn’t always better than older, cheaper and less technical. It’s obscured by the Washington fights over coverage. But it’s deeply important and potentially transformative.

The U.S. system is a bizarre blend of undertreatment and overtreatment, a mélange of “the best care in the world” and a system rife with quality control, infection, complications and error rates that would not be countenanced in other settings. All of that is affected by health reform.

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