There is no debating that the ACA contains benefits and costs and that the law continues to sharply divide the country. Its supporters say that it is working, while its opponents argue otherwise and continue pressing to undo the law. In January, Congress sent a bill to the president's desk that would have repealed large swaths of the law, including most of its taxes and much of its spending; as expected, the president vetoed the bill. Let's take a closer look at how ACA is working so far.
ACAs Impact on Coverage
The numbers have increased: ACA supporters primarily and repeatedly cite the decrease in the number of people without health insurance. The Obama administration estimates that 12.6 million people gained insurance coverage from 2010 to 2014. However, several million people became uninsured during the financial crash of 2008-2009. Part of the post-2010 increase simply reflects a return to pre-recession coverage levels as the economy has slowly improved. Using a 2008 starting point reveals that the number of uninsured fell by only 6.7 million people through 2014.
Most of the increase is Medicaid: The net gains in health insurance have come mainly through Medicaid and not private insurance, since the number of people covered by employer-sponsored insurance has somewhat declined. Medicaid is a program for lower-income people and is plagued with problems, including poor access to care for enrollees. A recent study found that enrollees receive only 20 to 40 cents of benefit for each dollar that Medicaid spends on their behalf.
Exchanges are doing poorly: Overall enrollments on the ACA exchanges are far lower than the government had previously forecast. The only people signing up in large numbers are those who receive large subsidies to reduce their premiums and deductibles.
Importantly, increasing the number of people with insurance cards does not guarantee that those people gain anything in terms of health, as numerous studies have indicated a loose connection between health insurance and health.
ACA's Impact on Insurance and Premiums
Premiums soar: President Obama told Americans that ACA would reduce family premiums by $2,500. However, since ACA was signed into law, family premiums for employer plans have soared — increasing by more than $4,000 since 2009.
Young and healthy decline to subsidize old and sick: ACA requires that health insurers offer a standardized health insurance product to all applicants, and that they charge the same premiums regardless of health status. Insurers are also prohibited from charging near-retirees more than three times the amount charged to twenty-somethings. As a result, ACA increased individual-market premiums, with younger and healthier people bearing the largest increases.
In 2014 and 2015, insurers selling exchange plans lost money as the plans attracted older and sicker enrollees than expected. In 2016, most exchange-plan premiums are increasing by double-digits. UnitedHealth, the largest insurer in the country, has announced that it may stop offering exchange plans altogether after 2016 because of market instability.
Plans are becoming stingier: Premiums would be even higher, but insurers designed exchange plans with very narrow provider networks and high deductibles and cost-sharing amounts. Many are discovering that their treatments are “covered” under their plans, but not actually paid for by their plans.
ACA's Impact on Businesses and Workers
Employer mandate arrives in full force: After two years of delay, the employer mandate takes full effect in 2016. The employer mandate requires that employers with at least 50 full-time workers offer acceptable coverage to their workers or pay tax penalties. These penalties can equal $2,000 per worker or $3,000 per worker receiving insurance subsidies on the exchanges. The mandate incentivizes employers to trim hours below 30 per week so workers are not considered full-time and reduce full-time workers (plus full-time equivalents) below 50.
Paperwork will become heavy: The IRS has created seven new forms for ACA. In particular, complying with the employer mandate will be a major paperwork burden for businesses. Businesses will have to report on their health-insurance offering as well as the monthly take-up rate for their workforce.
SHOP exchanges are mostly failing: The Small Business Health Option Program exchanges were designed to provide small businesses the ability to offer their workers more health-insurance options and lower overall premiums. Thus far, the SHOP exchanges have been a failure, enrolling only a small fraction of the number of people projected.
Co-ops have failed: All of the co-ops — state-based insurers established by the law through large federal startup loans — are underwater. More than half have already closed.
Fewer jobs: The Congressional Budget Office estimates that ACA will reduce the amount of full-time work in the economy by about 2 million jobs, decreasing American economic output by about half of 1 percent. This is largely the result of lower-wage workers' working less because additional work would reduce or eliminate subsidies.
Insurance-company subsidies were reduced and are ending: ACA contained two back-end subsidy programs to assist insurers offering ACA plans. The first, called reinsurance, pays the majority of the costs of insurers' most expensive enrollees. The second, called risk corridors, collects money from insurers with profits and pays insurers with losses. Congressional action required the risk-corridor program to be budget-neutral so taxpayers would not be on the hook for insurers' losses. That made a big impact, since a lot more insurers lost money than made money on ACA plans in 2014 and 2015. Insurers were upset by this action and are lobbying for taxpayers to finance the risk-corridor deficit. Both reinsurance and risk corridors end after 2016, so ACA plan premiums in 2017 will have to rise, perhaps substantially, to account for the loss of these back-end subsidies.
Individual mandate tops off: ACA supporters hope that the increase in the individual-mandate penalty, which will now equal the greater of $695 per person or 2.5 percent of household income above the tax filing threshold, will incentivize more young and healthy people to purchase coverage and stabilize the risk pools. To date, the individual mandate has not been nearly as effective as many experts had predicted it would be.
Cadillac tax faces an uncertain future: The Cadillac tax was primarily placed in the law as a way to deal with the tax exclusion for employer-provided insurance, which means that employer plans' premiums are not subject to federal income or payroll taxes. Economists generally agree that the tax exclusion causes numerous problems and contributes to the high cost of American health care. The Cadillac tax was slated to begin in 2018 and was a 40 percent excise tax on plans valued at more than $10,200 for single coverage and $27,500 for family coverage. After aggressive lobbying by business and labor groups, Congress delayed the Cadillac tax until 2020. Among people who believe the exclusion needs to be capped or limited, the Cadillac-tax delay raises concern that will ever happen.
Six years after enactment, ACA remains a law very much in turmoil. The law has decreased the number of people without health insurance, and its regulations and subsidies have benefited some lower-income people and many with preexisting health conditions. Many more, however, find they have less freedom and that their coverage is deteriorating: higher premiums, fewer providers, higher out-of-pocket costs. Beyond the widely reported website problems, many of the law's fundamental institutions — individual exchanges, SHOP exchanges, co-ops, mandates — are failing to perform as expected.
The law will certainly be one factor in this year's elections. Obviously, its long-term future depends heavily upon who is elected president. But perhaps more important is whether public pressure from higher premiums, higher taxes, and reduced choices will boil over and force Washington to revisit the law regardless of who is elected president.