Since its passage in 2010, the Affordable Care Act has been a living, breathing piece of legislation that continues to evolve, adjust and adapt. Whether through regulatory changes, legislation, or world-shaking events, the law has continually improved to address concerns and help bring more Americans into coverage.
ACA – The Big Picture
In the years prior to the ACA, health insurance costs and benefits were often unaffordable for many families. The ACA addressed this by reducing cost-sharing for low-income Americans and introducing tax credits to help them afford health coverage. The ACA also expanded the eligibility for Medicaid and established new health insurance marketplaces where individuals can shop for coverage on a level playing field. In addition, the ACA required employers to offer affordable workplace coverage or pay a penalty.
Among other things, the ACA prohibits insurance companies from discriminating against consumers based on preexisting conditions or gender. It also prevents insurers from imposing annual or lifetime dollar limits on coverage. Prior to the ACA, an estimated 50 million to 129 million Americans lived with coverage limitations that prevented them from getting the care they needed.
To further improve health insurance affordability, the ACA requires all plans to provide 10 essential benefits, such as hospitalization and emergency services, prescription drugs, mental and behavioral health services, and women’s reproductive healthcare. The ACA also makes evidence-based preventive services available for free to most adults.
The ACA also regulates how medical claims are processed and pays, simplifies billing with standardized identifiers, and establishes consumer protections, including the right to appeal denied claims and a requirement that health insurance companies notify patients of their premium status at least 60 days before the first bill is due.
Lastly, the ACA promotes integrated health systems by providing incentives for physicians to work together in accountable care organizations and other collaborative models. These partnerships allow doctors to better coordinate patient care, improve quality of care and reduce costs.
In the wake of the COVID-19 pandemic, the ACA has continued to expand coverage, simplify the application process for individual and small group health insurance, and increase financial assistance available to help make marketplace coverage more affordable. It has also increased the minimum age to purchase tobacco products and lowered the maximum cost-sharing for Medicare Advantage plans. Congressional action through the American Rescue Plan of 2021 and the Inflation Reduction Act of 2022 have made even more improvements to ACA financial assistance. However, more action is still needed to create a pathway to affordable health coverage for the 1.6 million people in non-expansion states who are stuck in the “coverage gap” because their incomes are too high to qualify for federal financial help with marketplace coverage but don’t have access to Medicaid in their state.