Research Article: The US Affordable Care Act: Reflections and directions at the close of a decade

Date Published: February 26, 2019

Publisher: Public Library of Science

Author(s): Adrianna McIntyre, Zirui Song

Abstract: In this month’s Editorial, PLOS Medicine Academic Editor Zirui Song and his colleague Adrianna McIntyre discuss outcomes and possible futures for the United States Affordable Care Act as it nears the ten year mark.

Partial Text: The ACA expanded insurance coverage in two principal ways. First, it created health insurance marketplaces at the state level on the premise of competition and choice; individuals could compare similar coverage options and choose among competing plans. The health law also provided low-income individuals and households up to 400% of the federal poverty line with subsidies to help them purchase insurance. Second, the ACA expanded eligibility for the Medicaid program to individuals and families with incomes up to 138% of the federal poverty line—about US$35,000 for a family of four. Since the law’s implementation in 2010, the number of uninsured people in the country has fallen by about 20 million [2].

The law has endured numerous legislative challenges following its passage. The House of Representatives advanced over 50 bills to repeal the ACA in whole or in part, with the Senate voting on a subset of them [4]. These started out as largely symbolic—a presidential veto was virtually guaranteed while President Obama was in office—but began to pose an existential threat to the ACA under a unified Republican government that held power during the first two years of the Trump administration. The narrow 49-to-51 vote defeat of the last prominent repeal effort in the summer of 2017 illustrated the tenuous grounds upon which the law sat in the previous Congress. However, its survival was also a testament to its legislative durability; the political challenge of withdrawing health benefits shared across different constituencies has thus far been insurmountable, despite lukewarm public opinion on the law.

The prospects for near-term repeal have diminished with Democrats taking control of the House of Representatives, but the ACA has not receded from the public debate. On the contrary, healthcare ranked among voters’ most important issues in the 2018 midterms. The administration and new Congress will need to decide whether to leave the law alone or modify it. Additionally, attempts to weaken the law through regulatory channels will be subject to increased scrutiny now that Democrats have more congressional oversight.



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