As the Affordable Care Act (ACA) reaches the tenth year of its enactment, there is renewed question on whether it has delivered on its promise of universal health care to all Americans.
During the original congressional debate over whether the ACA should be implemented, proponents argued that the new program would ensure that all Americans, regardless of income, would have access to affordable health insurance. According to lawmakers, low-income people would receive generous subsidies that would enable them to purchase plans on newly created federal and state exchanges. States would also be allowed to cover additional low-income people by expanding Medicaid, and people with pre-existing conditions could not be denied coverage under the ACA.
To help cover the cost of the program, all Americans would be required to have health insurance or pay a penalty to the IRS. This individual mandate went into effect in 2014 after a 2012 Supreme Court ruling declared the penalty constitutional as a tax under Congress’s tax-writing powers. The penalty was subsequently repealed in the December 2017 tax reform.
29 Million No Insurance
However, the health insurance coverage numbers have not borne out the promise of Obamacare, according to Linda Gorman, a senior fellow at the Goodman Center for Public Policy Research and director of the Health Care Policy Center at the Independence Institute.
“Although private individual coverage grew by 5.3 million from 2014 through 2016, private coverage in the employer market fell by 3.6 million,” Gorman wrote in a 2018 analysis. “As a result, Obamacare witnessed a net increase of a mere 1.7 million people—slightly less than half of the natural increase in the civilian labor force.”
In a September 2019 release, the U.S. Census Bureau reported that the number of Americans without health insurance had risen for the first time in a decade in 2018, by about 2 million people. The Bureau found that 8.5 percent of Americans went without medical insurance in all of 2018, up from 7.9 percent in 2017. It was the first year-to-year increase in the percentage of the uninsured since Obamacare went into effect. Although the number is still below the 13.3 percent uninsured rate in 2013 prior to Obamacare taking effect, the rise means that about 29 million Americans are still without health insurance.
Disabled on Waiting Lists
Medicaid expansion to able-bodied adults, which proponents said would ultimately benefit those with disabilities and chronic illnesses, was one of the cornerstones of Obamacare. However, it turned out to be far more expensive than predicted and may have actually harmed those with disabilities.
The Centers for Medicare & Medicaid Services (CMS) Office of the Actuary estimates that the federal government spent $148.2 billion on Medicaid expansion from 2014 through 2016. Originally expected to cost just $3,500 per enrollee, the price taxpayers were footing rose to nearly $6,000 per enrollee by the end of 2016. Furthermore, the Obama Administration’s decision to reimburse states for 90 percent of the cost of able-bodied, working-age adults in Medicaid had a profound effect on the program.
“Expanding Medicaid to this group cost $148 billion from 2014 through 2016, money that could have been used to reduce the waiting lists for care for the disabled,” Gorman said. The federal government reimburses traditional Medicaid enrollees at a lower rate and because of that, states limit enrollment
Red Tape at Expense of Patients
Largely hidden from public view are Obamacare’s reporting requirements for what are called “quality measures,” which have increasingly taken up the valuable time of physicians and hospitals.
“Virtually all published studies on the value of Obamacare quality measures ignore whether the quality gains would have occurred anyway,” Gorman writes.
Additionally, physicians have had to spend a growing amount of time on electronic health records (EHRs). A 2009 statute, the Health Information Technology for Economic and Clinical Health Act (HITECH), has combined with Obamacare record-keeping requirements.
The U.S. health care system was already using electronic medical records, where it made sense. However, HITECH’s meaningful use requirements made data entry a time-consuming task for physicians. A September 2017 Annals of Family Medicine study by Brian Arndt, et al. found that physicians spend two hours on EHRs for every one hour of direct patient care.
Government Health Care Moving Forward
Families who seek insurance in the individual market and don’t qualify for federal subsidies have found their premiums to go up significantly, states John Goodman, co-publisher of Health Care News and co-founder of The Goodman Institute.
“What we were promised was access to the type of insurance people used to get at work,” John Goodman, president of the Goodman Institute, wrote in a March 2020 analysis. “What we got instead was something that increasingly looks like Medicaid with a ridiculously high deductible.”
In March, the U.S. Supreme Court agreed to hear a Texas-led challenge to the ACA, which argues that, in the wake of the repeal of the individual-mandate penalty as a tax, the entire law should be invalidated. The court will hear the case this fall and is expected to hand down a decision after the November 2020 election.
“For me, the most salient feature of the case is the Trump administration’s refusal to defend the statute without abandoning it completely,” says Charles Silver, who holds the chair in civil procedure in the School of Law at the University of Texas. “The ACA is a bad program that we’d be better without, but the responsibility for repealing it should rest with Congress and the Executive, neither of which wants it or is capable of handling it.”
Bonner R. Cohen, Ph.D., (firstname.lastname@example.org) is a senior fellow at the National Center for Public Policy Research and a senior policy analyst with the Committee for a Constructive Tomorrow (CFACT).
Linda Gorman, “What Are We Getting for Our Obamacare Dollars,” The Goodman Institute for Public Policy, August 2018: http://www.goodmaninstitute.org/wp-content/uploads/2018/08/BA-126-What-Are-We-Getting-for-Our-Obamacare-Dollars.pdf