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Topic overview

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.”

Now with President Donald Trump in the White House and Republicans in the majority in both house of Congress, the fate of the health law is uncertain. The president and the congressional Republicans promised swift action to repeal the law. But it turns out that uprooting a law that has been on the books for seven years and is covering about 20 million Americans is harder than it looks.

Back in 2010, when the law was enacted, the ACA was forecast to cover about 32 million Americans by 2019, a forecast that gradually dropped amid barriers to implementation and persistent political opposition. The complex, multipart legislation remains highly divisive and misunderstood. Political and policy uncertainties have shadowed, threatened and changed implementation. Now, in early 2017, Republicans seem certain to change the law, and to include more market-oriented features and state flexibility. But the scope of the changes are not yet clear. House Speaker Paul Ryan and Secretary of Health and Human Services Tom Price have championed a wholesale conservative replacement, relying on health savings accounts, high risk pools, and a deregulated market. But there are also voices (including some Republican governors) calling for a less dramatic “repair” – a scaling back, yes, but in a way that retains some of the contours and coverage of the ACA (even if it’s rebranded as “TrumpCare.”)

The political fights around the law during the Obama administration led to two major Supreme Court challenges. The court in 2012 upheld its constitutionality – but ruled that the Medicaid expansion was optional for the states. That turned out to have long-lasting implications, as 19 states have still not expanded, affecting both the coverage in those states and the financial health of their hospitals and other providers. The second Supreme Court case, King v. Burwell, challenged a core provision – the insurance subsidies for millions of Americans getting covered through – but in June 2015 the court upheld the subsidies. At the time it was seen as the last existential challenge to the law. Then came the 2016 election.

Throughout all the conflict, one thing has been clear. Whatever the law’s flaws, it has led to steady gains in coverage, even in the states that shunned Medicaid expansion. The latest CDC survey found that the uninsurance rate has dropped steadily to about 8.8 percent– the lowest rate since the CDC started tracking coverage in 1972. More than 20 million had gained coverage by early 2016. Critics point out that roughly 30 million people are still uncovered (including undocumented immigrants who are ineligible for coverage). But 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 online portal on Oct. 1, 2013. Even after was repaired and working smoothly, most states (including some Democratic-governed states) stuck with, or shifted to, the federal exchange rather than running their own.

Political and pragmatic delays repeatedly 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.)

Yet while the legal and legislative battles rage, the law began 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 2017 season got off to a good start – but ended below the admittedly modest projections, arguably because the new administration rolled back outreach in the crucial final days of the open enrollment season, a time when many younger and healthier customers sign up. 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. The disaster scenarios – overcrowded hospitals, extremely long waits for health care, a collapsing financing system, and a job-killing effect on the overall economy – have not come to bear. Premiums did rise more sharply for 2016 and 2017 than the first two years, with a few states registering particularly high spikes. (Republicans’ success in blocking billions in payments the law had designated for insurers to help them navigate the risks of the first few years contributed to the premium increases as the health plans passed costs onto customers.) 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. The Republicans working on repeal are divided over whether to kill all those taxes for good, or keep some in reserve for ongoing (though smaller) subsidies for insurance under an ACA replacement.

Health care reform is sprawling and complex, with moving parts and unintended consequences. Health spending represents more than one-sixth of the economy - it neared $3.4 trillion in 2016  , and the rate of growth has ticked 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. 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, subsidies for low-income groups, or affordability of insurance policies and health care itself.

But health care policy isn’t only about covering more people. The 2010 law touches on just about every aspect of health care. Delivery system reform (a clunky and confusing phrase that many of our readers and listeners may think pertains to the fate of Saturday mail service) is changing how Americans receive care, and how doctors and hospitals are paid for providing that 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 – no matter what shape it finally takes under the Trump administration. 

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