Two weeks ago marked the tenth anniversary of the enactment of the Affordable Care Act (ACA). Given the ongoing COVID-19 pandemic, which Mintz has been closely monitoring, it is understandable why the anniversary has largely flown under the radar. However, now is as good a time as any to reflect on all the controversy that has surrounded the law over the last decade, as well as how much the law has accomplished. While far from comprehensive, our upcoming blog series will review some of the impacts the law has had on the U.S. healthcare system, in particular focusing on the legal issues and debates that have surrounded the law. Mintz has previously covered many of these items, and links to our prior coverage is included throughout.
Around noon on March 23, 2010, as he finished signing the ACA into law in the East Room of the White House, then-President Barack Obama concluded the ceremony by remarking: “We are done.” He was specifically joking about the literal amount of time he had just spent physically executing his signature on the bill because of the number of pens he had to use, though one also could have easily interpreted that statement to have dual meaning. At the time, enactment of ACA appeared to be the end of not just the contentious legislative process that preceded its passage, but also the completion (on some level) of the Democratic Party’s long-standing objective of passing significant health care reform legislation.
There were several signs even in March 2010 that the ACA would be subject to years of legislative and judicial disputes. Among other reasons, the legislation was enacted with no Republican votes and with the Senate employing the budget reconciliation process, thereby requiring only a simple majority for enactment. Additionally, as the President made his remarks, Florida was concurrently filing a lawsuit in federal district court challenging the constitutionality of two major provisions of the law: the individual mandate and the Medicaid expansion. That case, which was later joined by 25 other states and private plaintiffs including the National Federation of Independent Businesses (NFIB), would become the first significant legal challenge to the ACA. In the last decade, the ACA has been the subject of myriad court battles, a handful of which have reached the Supreme Court. There have also been significant legislative attempts to repeal either portions or the entirety of the law, one of which is currently pending in the Supreme Court.
As a result of some of these high-profile cases, many other, unchallenged provisions of the law have received less attention. The impact of such provisions are nevertheless important. Despite the simplicity of the ACA’s goals – to increase access to health insurance for uninsured individuals and lower the cost of coverage for those already insured – the ways in which the law sought to accomplish these aims were wildly complex and interconnected and have resulted in fundamental changes to several aspects of the U.S. healthcare system. This complexity is reflected in the major components of the law, which we will examine throughout this blog series, including:
- An “individual mandate” requiring most individuals to obtain health coverage or pay a penalty, along with an “employer mandate” requiring most employers with 50 or greater full-time equivalent employees to provide qualifying health coverage;
- Requiring states to expand Medicaid eligibility to low-income adults;
- Requiring health plans to comply with federal standards for health coverage;
- Establishing health insurance exchanges where individuals and small employers could purchase qualifying health coverage, along with means-tested subsidies to help individuals pay for the premiums and subsidies for these marketplace plans, and premium stabilization programs to mitigate market failures; and
- Implementing various programs to test alternative payment models.
Notwithstanding the law’s various interlocking components, the ACA as a whole has had a substantial impact in reducing the number of uninsured Americans. There is a growing body of evidence showing improvements in access to care and lowering of the health care cost inflation curve as a result of the ACA. Between passage of the law in 2010 and 2017, the number of uninsured in the U.S. dropped from 44.2 million to 27.4 million (17.8% and 10.2% of the population, respectively). While the uninsured rate in 2010 was arguably inflated due to the number of people who became unemployed as a result of the financial crisis, it is notable that the steepest decline in uninsured individuals coincided with the implementation of major provisions of the law. As a result, more than 20 million people gained coverage during this period.
Early studies on the law also provide evidence of improvements in access to care, quality of care, and health outcomes for non-elderly adults. A recent Commonwealth Fund survey found that between 2010 and 2018, the share of non-elderly adults who reported having a problem paying a medical bill fell by 17%, the percentage who did not visit a provider when needing care fell by 19%, and the share who skipped a test or treatment fell by 24%. There is also evidence that the ACA has led to improvements in certain economic measures and a reduction in overall health care spending. In 2019, CMS released updated projections of national health expenditures and found that between 2010 and 2019, actual spending was significantly lower than pre-ACA projections, with spending in Medicaid, Medicare, and by private insurers dropping 21.5%, 18.2%, and 6.1%, respectively, from CMS’s pre-ACA projection.
Tomorrow, we will cover the ACA's most controversial reform, the individual mandate.
 For example, this blog series will not touch on some high-profile components of the law, such as the action surrounding the Cadillac Tax, or the Supreme Court case Burwell v. Hobby Lobby, both of which Mintz has written about on the blog. Please refer to our posts on these subjects for more information.
 Gov’t Printing Office, Administration of Barack H. Obama, 2010 Remarks on Signing the Patient Protection and Affordable Care Act March 23, 2010: https://www.govinfo.gov/content/pkg/DCPD-201000196/pdf/DCPD-201000196.pdf.
 The enactment was further complicated by the unexpected victory by then-Senator Scott Brown to the late Senator Ted Kennedy’s seat via a special election, which occurred after the Senate passed its version of the bill, but before the final Senate and House bills could be reconciled in joint committee and the final text could be passed by both chambers. To avoid having the Senate vote once more on the final bill, the House adopted the full text of the Senate’s bill, which no one had expected to be the final draft of actual legislation signed into law. The House then had to rely on the Senate to pass a “corrections bill” to address any changes the House wanted to the final legislation. The Senate used a parliamentary tactic called budget reconciliation to pass the corrections bill, but the corrections bill included several errors, including its failure to necessary appropriations language for several programs. See John F. Cogan, "The High Cost of Good Intentions: A History of U.S. Federal Entitlement Programs" (2017).
 C. Stephen Redhead and J. Kinzer, Legislative Actions in the 112th, 113th, and 114th Congresses to Repeal, Defund, or Delay the Affordable Care Act (February 7, 2017).
 S. Collins, H. Bhupal, and Michelle Doty, The Commonwealth Fund, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured (Feb. 2019),
 Additionally, there is a growing body of evidence showing improvements in economic measures as a result of the ACA, including changes to payor mix and other impacts on hospitals and providers, improvements in state budgets and economies, Medicaid spending per enrollee, and positive improvements in employment and labor markets. M. Guth, R. Garfield, and Robin Rudowitz, Kaiser Family Foundation, The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review (Mar. 17, 2020). For example, two recent studies examining some of the secondary effects of the Medicaid expansion have also found decreases in the prevalence of severe food security and large reductions in the coverage gap in states that expanded, respectively. Gracie Himmelstein, “Effect of the Affordable Care Act’s Medicaid Expansions on Food Security, 2010–2016”, American Journal of Public Health 109, no. 9 (September 1, 2019): pp. 1243-1248.
 Paul N. Van de Water, Ctr on Budget and Pol’y Priorities, More Evidence of Post-ACA Slowdown in Health Care Spending.