FAH Hospital Policy Blog

Perspectives on health policy affecting America's hospitals and the patients we serve.

11th Anniversary of the Affordable Care Act

This week marks the 11th anniversary of President Barack Obama signing the Patient Protection and Affordable Care Act (ACA) into law. Since then, the ACA has been a literal lifesaver ensuring tens of millions of Americans access to affordable health care.

As I have said before, the passage of the ACA is one of the proudest moments of my career. Since I started working on health policy in Washington in the 1980’s, we have always chased one holy grail – making sure all Americans had health coverage. It was a goal that many sought – from groups that wanted to stretch the current private-public insurance system to those who wanted to socialize care.  Compromises were considered and fell by the wayside over the years.

In ’93 and ‘94, President Clinton pursued ClintonCare, but those efforts ultimately fell short in Congress. One of the main reasons for failure, the President tried to impose the plan he developed on the Congress and did not invite real input from many of the key stakeholders. With the critical voice of so many missing, the plan took a wrong turn and ended up a non-starter with many lawmakers – and the public. It was clear there was support to cover all Americans, but for it to become a reality you needed a broadly backed plan. My work with others developing the Harry and Louise ads early during the consideration of ClintonCare highlighted important questions many felt were unanswered by the administration at the time.

While the effort failed, the need remained. Hospitals and physicians were seeing patients in the emergency rooms without insurance and still others who could not afford proper coverage missed out on important care. The momentum to act never truly faded– and eventually it led to the creation of the ACA!

The Obama Administration and key leaders in the Congress moved forward recognizing the importance of building on what worked in the existing system and addressing the concerns of key stakeholders. Leaders from health care, consumers, small business and large employers came to the table to work with the Obama administration to develop a comprehensive private-public plan that worked for all Americans. It was a difficult process. No group got everything they wanted, but – united in the need to act on behalf of the tens of millions of uninsured Americans and the coverage security of the whole nation – 11 years ago the ACA became the law of the land.

Unfortunately, since its passage the ACA has not had a simple path to meet its aspirations. It was first undercut by poor implementation, then the Courts and the Congress. From the very beginning, the ACA started off on poor footing because of the rocky Healthcare.gov launch. The courts have also hindered the ACA with rulings that slowed Medicaid expansion, and the Supreme Court is even now considering the law’s fate when it rules on the case, Texas v. United States.

Then there is the political divide – for the last decade Congress has been unable and unwilling to make the important updates and changes to improve the ACA – an evolutionary process that had typically followed the passage of other ground-breaking laws.

But the atmosphere is improving, and the winds of change seem to be pushing the ACA forward in 2021. The pandemic and the election of an ACA-friendly White House and Congress have already led to legislative and regulatory actions aimed at increasing access. There now is a clearer course to coverage for all Americans through the ACA framework.

The newly enacted American Rescue Plan Act lays out a pathway to improved subsidies for individuals and provides incentives for the holdout states to expand Medicaid to adults. The opportunity is great and in the 11th anniversary year one can start to feel we are really on the way to achieving the full promise of the ACA.

But we must keep pushing forward, which is why FAH supports these proposals that will help the law reach its complete potential by covering more patients:

Medicaid Expansion

  • Encourage all the states to fully provide ACA Medicaid expansion to adults. Originally under the ACA, states were required to expand Medicaid – but after court interference, many Americans never got the health coverage they so badly need. The recently enacted American Rescue Plan Act encourages remaining states to expand their Medicaid programs by offering a two-year enhanced federal match for the non-expansion population.

Extended Eligibility for Middle-Income Americans

  • Establish more generous federal premium tax credits to make insurance more affordable and help to stabilize the individual market. The American Rescue Plan Act sets us on the right path by enhancing premiums subsidies for 2021 and 2022, which will help more Americans afford needed coverage.

Insurance Affordability Fund

  • Establish a sustained federal funding mechanism to support any unexpected high costs for caring for those with serious health conditions or to otherwise lower premiums or cost-sharing for exchange enrollees. This would incentivize insurers to cover expensive treatments for those who need it while reducing premiums for the general population.

Pre-existing Condition Protection

  • Maintain the ACA’s plan to provide sufficient coverage for Americans with pre-existing conditions, allowing the ability to meet their medical and behavioral health needs. That can only be achieved by ensuring access to the kind of clinician and hospital services that Americans depend on and which anyone with insurance should reasonably expect.

Increase Outreach and Enrollment

  • Increase awareness of eligibility and help people find the coverage they need. Whether it was eliminating the individual mandate, shortening the enrollment period or cutting funding for navigators, actions by past Congresses and the previous administration weakened the ACA by reducing enrollment. The Biden Administration has already begun reversing these decisions by opening a special enrollment period and providing funding for outreach as well as Navigators to assist people seeking coverage.

The ACA is more popular than ever with close to 60% of Americans supporting the law. The adjustments started by the Biden Administration and Congress through the American Rescue Plan Act will enable it to help more people across the country. But there is more to do. FAH urges Congress to further embrace the spirit of the law and build upon what’s currently working so that it can help millions more.

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