The Patient Protection and Affordable Care Act (Affordable Care Act, ACA, “Obamacare”) is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Representing the most significant regulatory overhaul of the United States’ healthcare system since the introduction of Medicare and Medicaid in 1965, this law was designed to increase accessibility to health insurance coverage, expand the requirements for health insurance, and require the creation of health insurance exchanges to provide ease of access to insurance options. The costs for expanding healthcare coverage were projected to be offset by increased taxes and reduced Medicare and Medicaid spending (Chaikind et all 2011,1).
Lyndon Johnson’s “Great Society” social reforms of the 1960’s included healthcare reform through Medicare for senior citizens and Medicaid for individuals who can’t afford healthcare. Through the 1970’s, fueled by Cold War anti-socialism sentiment, efforts to pass universal healthcare failed. By the early 90’s, the Clinton Administration had campaigned on bringing healthcare to all Americans. However, the Health Security Act of 1993 (HSA, “Hillarycare”), which would have irrevocably entitled all Americans to health insurance, failed after losing political support (PBS 2012). In 1997, the State Children’s Health Insurance Program (CHIP) was enacted by President Clinton, guaranteeing health insurance to poor children. Leading up to the election of Barack Obama, and under the Bush Administration, expansions to Medicaid and CHIP were vetoed, and no major revisions to the current laws were enacted until the passing of the ACA in 2010.
The conditions surrounding the passage of the ACA allowed the ACA to succeed when other health care reform proposals had failed in the past. In 2009, most people received their health insurance coverage through employer sponsored insurance (ESI). Specifically, 58% of the nonelderly American population received insurance through their employer (Claxton et al. 2016). However, since 1999, the number of people covered through ESI was dropping. In 1999, 67% of the nonelderly received coverage through ESI (Claxton et al. 2016). Factors that contribute to this decrease in ESI include less employers offering insurance due to rising health care costs and changes in the labor market (Claxton et al. 2016). Therefore, there was a need for different sources of health insurance and the ACA was implemented to provide coverage for all of those people who were no longer able to receive insurance from their employer or for people who didn’t originally qualify for ESI.
Figure 1. Percent of the Nonelderly Population Enrolled in Employer-Sponsored Coverage, 1999-2014 (Claxton et al. 2016).
The ACA used several avenues to achieve its broad goal of improving healthcare access and affordability. The ACA achieves this through expansion of Medicaid eligibility, extending funding for the Children’s Health Insurance Program (CHIP), and subsidizing private-insurance premiums for individuals enrolled in private exchange plans. Additionally, a main tenet of this legislation is the inclusion of measures designed to enhance the delivery and quality of care (Collins et all 2017). In the health policy world, the ACA is often described as the “Three-Legged Stool” when defining the main tenets that the act focuses on. With universal coverage being the main goal, the ACA has three main categories, each being a leg on the stool—guaranteed issue through insurance market reforms, an individual mandate, and subsidies and Medicaid expansion (Gruber 2010). The image of a stool is used because taking one of these components away causes the entire ACA to fall apart.
The ACA also regulated the private health insurance marketplace, and introduced/ expanded state public health marketplaces. The ACA boasts a high standard in the quality of healthcare mandated through both of these methods for coverage. A plan qualified by the ACA to be acceptable coverage in the United States must cover emergency services, hospitalization, maternity care, mental health, substance abuse disorder service, prescription drugs, chronic disease management etc., with its scope not being limited to just these services. (National Association of Insurance Commissioners 2010, 1). Interestingly, the mandate for abortion coverage is left to a state opt-out decision. Furthermore, health insurance companies are not allowed to deny converge due to pre-existing conditions, and accessibility and nondiscrimination are emphasized. This is readily apparent for California’s health-insurance marketplace Covered CA, where bilingual services, technical support and information for people with disabilities are present on clear, easily navigable website. Additionally, a testimonial on this website from Amber Freitas (http://www.coveredca.com/real-stories/) explains the marketplace’s role in providing her self-employed family health insurance despite their pre-existing conditions.
In addition to its role in providing a more robust system of care, the ACA also was designed with affordability goals in mind. The Secretary of Health and Human Services at the time, Kathleen Sebelius, was lauded for “her relentless and effective work in eliminating the waste, fraud and abuse in Medicare and Medicaid (Committee on Health, Education, Labor and Pensions United States Senate, 2011). More than just its elimination of waste, the ACA introduced ‘premium assistance credits’ to help low-income individuals pay for their health insurance, while maintaining a net-neutral cost after elimination of tax-credits (Peterson, Gabe 2010, 2). However, the ACA has drawn much criticism for not hitting these intended targets.
Most major provisions of the Affordable Care Act did not take effect until 2014, however several legal challenges were mounted immediately after its passing challenging the individual mandate section and the federal requirement for States to expand Medicare. In 2012, the Supreme Court ruled that the individual mandate to purchase healthcare was a valid constitutional exercise of Congress’ taxation powers, yet mandated Medicare expansion was not, in its National Federation of Independent Business v. Sebelius ruling (Eastman 2012, 12). This setback to the law allowed states to decide if they wanted to opt into the program, and as of September 2016, 19 states had decided to not expand their program (Garfield, Damico 2016).
An interesting aspect of the ACA is the necessity for state-run health insurance marketplaces to advertise. The State of Oregon has undertaken this task, producing a promotional video that uses a song to link the health of Oregonians to Oregon’s natural beauty. “To care for each one, each Oregon son, long live Oregon” is its chorus, with the advertisement being more of a justification of the state’s adoption of Medicaid supplements and less promoting it citizen’s usage of the Covered Oregon online Marketplace (Glor 2013).
Public opinion surrounding the Affordable Care Act is very much defined by President Obama and people’s perception of him. Jimmy Kimmel did a segment on his show in which he walked around on the streets and asked people whether they liked “Obamacare” or “The Affordable Care Act” more (Jimmy Kimmel Live 2013). The video showed that people did not know that the two are the same and they generally preferred the Affordable Care Act over Obamacare. Negative public opinion towards President Obama greatly affected people’s perception of the ACA and influenced them to not support it, regardless of concrete knowledge of the components or the effect of the law.
The Affordable Care Act relates to the Politics of Health because it tests the role of citizenship in receiving health coverage. One major criticism of the legislation is that it leaves a large Coverage Gap, citizens that make too much money to qualify for the assistance credits but not enough to reasonably afford their own health coverage. In states that have not expanded Medicaid (19 states, 39% of the United States Population) 2.6 million individuals are currently in the coverage gap. Furthermore, 450,000 individuals are currently eligible for Medicaid, but do not have insurance. Despite their citizenship, their healthcare access is limited because of the state they live in and their income (Garfield, Damico 2017). Additionally, the ACA does not give unlawfully present immigrants the opportunity to purchase health insurance. According to the healthcare.gov website, only U.S. citizens, U.S. nationals and lawfully present immigrants are eligible for coverage through the Health Insurance Marketplace.
References
Chaikind, Hinda, Copeland, Curtis W., Redhead, C. Stephen, Staman, Jennifer 2011. “PPACA: A Brief Overview of the Law, Implementation, and Legal Challenges.” Congressional Research Service R41664:1-6
Claxton, Gary, Long, Michelle, Rae, Matthew. “Trends in Employer-Sponsored Insurance Offer and Coverage Rates, 1999-2014.” Kaiser Family Foundation. Accessed March 30, 2017. http://kff.org/private-insurance/issue-brief/trends-in-employer-sponsored-insurance-offer-and-coverage-rates-1999-2014/
Collins, S.R., Gunja, M.Z., Doty, M.M., Beutel, S. 2017. “How the Affordable Care Act Has Improved Americans’ Ability to Buy Health Insurance on their Own: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016.” Commonwealth Fund. 5:1-20
Covered California. “Accessibility” and “Real Stories.” Accessed February 13, 2017. http://www.coveredca.com/
Eastman, John C. 2012. “Hidden Gems in the Historical 2011-2012 Term, and Beyond.” Charleston Law Review 7:1-80
Garfield, Rachel, Damico, Anthony. “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid.” Kaiser Family Foundation. Accessed February 13, 2017. http://kff.org/
uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid
Glor, Jeff, Anna Werner, Long Live in Oregon: Covered Oregon, Television Advertisement, (2013, Portland, OR: CBS Evening News)
Gruber, Jonathan. “Health Care Reform Is a ‘Three-Legged Stool’.” Center for American Progress. Accessed March 30, 2017. https://www.americanprogress.org/issues/healthcare/reports/2010/08/05/8226/health-care-reform-is-a-three-legged-stool/
Hearing of the Committee on Health, Education, Labor and Pensions United States Senate. 2011. “Examining the Affordable Care Act, focusing on the impact of Health Insurance Reform on Health Care Consumers.” United States Government Publishing. https://www.gpo.gov/fdsys
/pkg/CHRG-112shrg80704/pdf/CHRG-112shrg80704.pdf
National Association of Insurance Commissioners. “Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges” http://www.naic.org/documents/committeesExchanges
Peterson, Chris L., Gabe, Thomas 2010. “Health Insurance Premium Credits in the Patient Protection and Affordable Care Act (PPACA).” Congressional Research Service R41137: 1-22
Public Broadcasting Service. 2012. “Health Care Crisis.” Accessed February 13, 2017. http://www.pbs.org/healthcarecrisis/history.htm
“Six of One – Obamacare vs. The Affordable Care Act.” Youtube video, 4:00. Posted by “Jimmy Kimmel Live”, October 1, 2013. https://www.youtube.com/watch?v=sx2scvIFGjE
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