In an article published in PLOS Medicine, health policy PhD candidate Adrianna McIntyre and assistant professor of health care policy and medicine Zirui Song, MD, PhD, discuss the past, present, and future of the Affordable Care Act.

Established in 2010, the Affordable Care Act (ACA) was passed with the goal of expanding insurance coverage and improving the health care delivery system in the United States. While there has been a substantial decline in the number of uninsured adults in the country, the ACA still faces challenges that make its impact and legacy uncertain.

The ACA has been successful in expanding insurance coverage through Medicaid and state-based exchanges on the premise of competition and choice. It provides low-income individuals and households up to 400% of the federal poverty line with subsidies that encourage their enrollment in insurance programs. Federal tax credits and subsidies make health insurance more accessible to low-income families and individuals, and federal programs were instituted to reduce incentives for insurers to select healthier enrollees and avoid sicker populations. Since implementation, the number of Americans without insurance has fallen by roughly 20 million.

Since its implementation, the ACA has also seen some challenges. The House of Representatives has advanced over 50 bills in effort to repeal the entirety or parts of the ACA. In 2012, the Supreme Court voted to scale back Medicaid expansion from a nationwide mandate to a state option. More recently, states have been granted new flexibility to modify their Medicaid programs in ways that could lower enrollment.

With Democrats holding the House in a divided Congress, repeal of the law is currently unlikely. Legislators must decide if they are going to leave the ACA as is or work to modify it in the current Congress. In 2018, House Democrats introduced a bill that would provide more consumer outreach and assistance, increase the availability of marketplace subsidies by lifting the income cap, and reverse certain regulations created by the current administration. However, they would need support from Republicans for this bill to pass into law.

Over the last few years, the public opinion of the role of the government in health care has evolved. In 2013, 42% of Americans believed that the government should ensure that all Americans have coverage. In 2017, that number had grown to 60%. This growing interest across the American public suggests that the country may be receptive to proposals that would move the health care system in a more progressive direction.