Yulian
The Affordable Care Act, commonly known as “Obamacare,” was enacted 14 years ago this week. This landmark legislation made sweeping changes to improve access to and quality of health coverage: It expanded Medicaid, established marketplaces for consumers to easily shop for health insurance, banned insurers from discriminating against people with preexisting conditions, created subsidies for middle-class Americans and required most insurance plans to cover essential health benefits including preventive services, mental health and maternity care.
It was controversial on its passage, but the ACA has proven itself resilient over the past 14 years, and now a majority of Americans view it favorably. However, former President Donald Trump has promised that, if elected again, he will work to repeal the law. So, before this November, it is important to take stock of what the ACA has been accomplished, what challenges remain and what bright spots are on the horizon.
Big accomplishments
The ACA has brought the uninsured rate to a historic low, sitting at approx 7.2% — less than half of what it was before the legislation; in New Jersey, the uninsured rate is even lower, at 6.9%.
Recent drops in uninsurance can be credited to the Biden administration’s signature packages, including extra premium tax credits under the American Rescue Plan to make health insurance more affordable. In 2022, the Inflation Reduction Act extended those expanded marketplace subsidies until next year. These subsidies save the average family $800 per year on top of existing savings and reach more families, which is especially important in high-cost states like New Jersey. New Jersey has particularly leaned into the ACA, standing up its own marketplace, Get Covered N.Jthrough which it provides additional subsidies for residents. As a result, New Jersey saw a enrollment records of 397,000 this year with 9 of 10 people qualifying for increased financial help.
The ACA also provided states with the option to expand Medicaid coverage to more low-income Americans. New Jersey was one of the first states to expand; since then, the number of states that have adopted Medicaid expansion continues to grow, increasing access for people currently in the coverage gap — where people earn below the poverty line but live in states that have not expanded Medicaid. Indeed, North Carolina just expanded Medicaid, which could benefit up to 600,000 people.
New efforts to increase coverage and affordability
Despite the successes of the ACA, challenges clearly remain. The coverage gap persists in 10 statesbut the good news is that several states — including Mississippi, Georgia and Alabama — are considering expansion.
Medicaid expansion is critical to advancing health equity, as Black individuals are more likely to be low-income and to live in non-expansion states, thereby falling into the coverage gap. Furthermore, people with disabilities experience poverty at over twice the rate of nondisabled adults, making Medicaid a key coverage option for those who do not qualify for Supplemental Security Income. States have the opportunity to improve access and equity across their constituencies by expanding Medicaid coverage.
Since noncitizen immigrants represent a large portions of the uninsured, expanding coverage options mitigates significant health disparities for these community members who experience limited access to affordable care. Most legal permanent residents are barred from accessing Medicaid for their first five years of residency and undocumented Immigrants cannot enroll in Medicaid or purchase marketplace plans. Bright spots do exist, however, as innovative states find ways to remove barriers to care, especially when it comes to pregnant women and children. For example, several states, including New Jersey, are stepping into the breach and using state dollars to provide coverage to noncitizen residents. California and Oregon are the first states to cover all immigrants who would be income-eligible for their Medicaid program. New Jersey, in its innovative”Cover All Kids” program, opened NJ FamilyCare to all qualified residents under age 19.
Navigating roadblocks ahead
The lingering impacts of the pandemic also pose challenges for sustainable health insurance coverage. The COVID-19 public health emergency expired in May 2023, and, while we “unwind” pandemic-era policies such as pausing Medicaid enrollment, we risk leaving people behind.
Medicaid unwinding — or the return to regular eligibility operations — has resulted in over 18 million people and counting losing their coverage, including about 360,000 New Jerseyans. Seven in 10 people nationally have been removed from Medicaid without having their eligibility reviewed. These disenrollments occurred for procedural reasons, such as out-of-date contact information and other bureaucratic hurdles. If Medicaid unwinding is not done effectively, we may lose progress in reducing uninsurance and disproportionately harm historically marginalized populations.
Furthermore, those enhanced subsidies from the Inflation Reduction Act expires next year. Families who were able to purchase marketplace coverage because of premium relief may lose insurance without them. As President Joe Biden called for in his 2024 State of the Union addresswe must extend these subsidies to secure continued affordability of coverage.
Finally, yet another legal challenge threatens part of the ACA. The Supreme Court has considered various challenges to the law, three times upholding its constitutionality, but a case winding its way through the courts threatens one of the most popular provisions of the ACA. The preventive services mandate requires insurance companies to cover services like cancer screenings, vaccines and contraception for free. A federal judge in Texas found elements of the requirement unconstitutional and recent oral arguments in the appeals court indicated they were likely to agreeso we can expect the Supreme Court to have yet another chance to reaffirm (or undermine) the law.
The Affordable Care Act has unlocked pathways for millions of people to access care. We are at a critical junction, however, in safeguarding the progress made over the past 14 years. In 2024, policymakers have the opportunity to secure the future of health access, as do voters who face a stark choice between bolstering the ACA or potentially dismantling it.