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The state of the Affordable Care Act, 10 years later

A recent poll found 59% of Americans have a positive view of the ACA, commonly referred to as Obamacare. But voters in the same survey said health care costs are still a top concern.
Posted at 8:40 AM, May 22, 2024

This year, a record 45 million Americans have health insurance thanks to the Affordable Care Act. Enrollment is up nearly 50% from just four years ago, and experts attribute that increase, at least in part, to expanded subsidies signed by President Joe Biden in 2022.

Some of the biggest increases in coverage happened in Southern, more conservative states.

"Many of them have not expanded Medicaid, which has contributed to their high uninsured rates," explained Cynthia Cox, vice president and director of the Program on the ACA for health policy research firm KFF. "But with these new subsidies that have been available, it's really helped people who were uninsured afford coverage for the first time."

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Ten years after the ACA marketplace's problem-plagued rollout, experts say both consumers and health insurance companies participating in the marketplace are doing well.

"We're seeing more insurance companies enter in. The trade-off here is that this costs the federal government more money," Cox said.

A February poll from KFF found 59% of Americans have a positive view of the ACA, commonly referred to as Obamacare. But in the same survey, voters said health care costs are still a top issue.

On the campaign trail, former President Donald Trump has repeatedly criticized the ACA, calling the cost "out of control" and saying America has one of the worst health care plans in the world. In a video released on Trump's social media platform Truth Social, he said "we're gonna make it much better, much stronger. In other words, make the ACA much, much better and far less money cost to the people."

When then-President Trump tried to repeal the ACA in 2017, the Congressional Budget Office estimated that within 10 years, 32 million people would lose health insurance and premiums would double. Throughout his first administration, Trump repeatedly said a new health care proposal was on the horizon, but he never released a plan.

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A letter signed by 48 health care officials — including military doctors and former surgeons general — raises serious concerns about a second Trump administration.

"While his specific policies are at best ambiguous, his track record and his words make clear the damage he would do," they wrote.

Cox echoed the sentiment in that letter.

"When Trump talks about making the Affordable Care Act better, it's hard to know exactly what that means," she said. "And I think what we experienced in 2017 is that the devil's in the details."

One major change Trump did accomplish in his first term was effectively repealing the individual mandate in Obamacare. Experts worried removing the requirement to have health insurance would have a negative impact on the marketplace.

Cox explained it like the carrot and stick analogy. The individual mandate was the stick, and the subsidies were the carrot.

"I think what we've learned is that people want health insurance, especially if you can make it affordable to them, they will take it up," she said. "You don't necessarily need to have a punitive kind of stick to convince people to get health insurance."

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Cox added that the main goal of the ACA was reducing the number of uninsured Americans and protecting people with preexisting conditions — which the law achieved. But there is still room to improve America's health care system.

Some people pay for health insurance but struggle to find an "in network" doctor nearby. Plus, the cost of health care services for society as a whole is still high.

The current subsidies credited with boosting health insurance coverage are due to expire in 2025. That will likely set up heated debate between the next Congress and the next president on whether those subsidies should be extended.