Thinking About Health: ACA has had positive effects, but many problems remain

The Affordable Care Act, nicknamed “Obamacare,” turns 10 years old this month, and what a tumultuous run the health care law has had. The law’s rocky existence hasn’t smoothed out yet, and it faces additional scrutiny by the U.S. Supreme Court in the fall, the result of more legal challenges to its future.

Nevertheless, the occasion of the law’s 10th birthday is a good time to take stock of what it has done and what it has not. How have Americans been helped? What serious challenges facing the health care system remain?

No matter what happens to the law on its latest trip to the Supreme Court, some changes have resulted that will continue to benefit millions of Americans.

The biggest one in my mind is that surveys show the public now generally believes everyone, sick or well, is entitled to buy health insurance. No longer is it acceptable to exclude people with preexisting health conditions. That’s a huge step forward in collective thinking about the country’s health insurance arrangements, and it is allowing people to begin a conversation about universal health coverage that I have never seen in my decadeslong career covering this topic.

Before the ACA passed, sick people who tried to get insurance were denied if they had any kind of preexisting ailment, even a minor one like an ear infection. If they did find a carrier to insure them, they often discovered that the very ailments they had were excluded from coverage.

Even if the ACA disappears, the principle that anyone, sick or well, must be able to buy insurance is likely to be enshrined in the country’s insurance arrangements. So are a few other changes like allowing young adults to remain on their parents’ policies until age 26 or lifting the caps on lifetime benefits, something that undoubtedly helps families with catastrophic illnesses.

But without a doubt the biggest plus under the law was to extend coverage to some of the country’s poorest citizens by making more of them eligible for Medicaid, a program passed as part of Lyndon Johnson’s Great Society reforms that now covers some 71 million Americans. About 40% are children.

“Childless adults got a major improvement in access to care,” Dr. Steffie Woolhandler, distinguished professor of public health at the City University of New York, said.

In 2012 the Supreme Court allowed states to decide whether to expand Medicaid coverage as the ACA provided. To date 14 states mostly, in the South and Midwest, have not done that, still leaving many of their poorest residents without medical help.

The biggest hole in the Affordable Care Act was the absence of any way to control medical costs, a problem now threatening the law itself as well as family budgets across the country.

“People can’t afford their care,” Woolhandler said. “Many people have insurance they can’t afford to use,” noting that last year families borrowed $84 billion to pay for medical care.

An NBC News/Commonwealth Fund poll released recently found that nearly half of likely voters with medical bills have used their savings including retirement savings to pay them, and 28% worry about receiving a surprise medical bill in the next year.

That’s a pretty grim result for a law whose official name is the Patient Protection and Affordable Care Act, sold with the slogan “affordable quality health care” a phrase crafted in the public relations shop of a Democratic pollster.

The law subsidized low-income people to help them buy insurance and pay the deductibles and coinsurance.

“If your income is below 250% of the poverty level, or $65,500 for a family of four, you’re feeling no pain,” insurance consultant Robert Laszewski said. “If your income is over 250%, you get no subsidies. You’re screwed.”

This year, the law said insurance companies may require families to pay as much as $16,300 and individuals to pay as much as $8,150 in out-of-pocket cost sharing. That includes deductibles, coinsurance and copays. Many policies set lower limits. Still, families incurring medical bills are likely to be on the hook for significant amounts of money.

With premiums for family policies exceeding $1,000 a month, it’s easy to see how the middle class is screwed.

Earlier this year, it looked like Congress might reevaluate parts of the ACA along with solutions to the high price of drugs. The health agenda has moved in a different direction for now, so the troublesome aspects of the ACA are likely to remain.

Has the Affordable Care Act impacted your family? Write to Trudy at [email protected].