Ten years of the Affordable Care Act comes to a close: A look back, and what to expect in 2020

When the ball drops and the clock strikes midnight, it will mark the end of not just the year but the decade. And over these past 10 years, arguably no health policy has received more scrutiny, praise, condemnation, controversy and attention than the Affordable Care Act.

Former President Barack Obama's signature health legislation was passed into law on December 24, 2009, marking a fundamental shift in Americans' access to health insurance. Before this past decade began, Americans had few insurance options beyond what was offered through their employers, and if they were unable to find work, that left them out in the cold.

The primary goal of the ACA was to expand access to insurance coverage, and in that measure it largely succeeded. The law established a Health Insurance Exchange, or marketplace, that offers varying degrees of insurance and at least a semblance of a safety net for those in danger of falling through the cracks.

Even with low unemployment figures, the numbers of people signing up for marketplace plans has remained relatively stable. This year, a total of 8,303,850 individuals enrolled, compared to 8,454,882 in 2018. That's a 1.7% drop in the number of people enrolling, but there are factors that may help explain the dip.

The Centers for Medicare and Medicaid Services, which administers ACA policy, recently said open enrollment is influenced by a number of factors. This year, the unemployment rate is at the lowest it has been in 50 years. And states such as Maine have expanded Medicaid, so that an estimated 12,000 people are now eligible for Medicaid in that state instead of tax credits.

Also this year, Nevada transitioned to a state-based exchange so that the CMS report totals do not include those consumers. At the end of open enrollment in 2018, about 84,000 consumers in Nevada selected a plan using HealthCare.gov.

Overall, 2019 enrollments added stability to the ACA market. Other stabilizing factors this year are a greater number of plans being offered on the exchanges, more insurers in the market, and lower premiums or premium increases. Instability exists in the question of whether the ACA is constitutionally valid.

That is perhaps the biggest legal challenge to the law, and efforts to repeal or dismantle it are still ongoing.

LEGAL CHALLENGES

An appeals court this month upheld a lower court's ruling that the individual mandate of the ACA, which required individuals to get coverage or face a tax penalty, was unconstitutional. The court sent a decision on whether the ACA could stand without the individual mandate back to a district court in Texas.  Republicans and the Trump Administration have attempted to repeal the law.

Whatever decision comes out of the lower court could send the fate of the ACA to the Supreme Court, but for 2020, the market is set and is expected to remain stable.

What's more uncertain is what will happen to the ACA after the presidential election in November. The results of that election could be a bellwether for the law's ultimate fate. The GOP has long been opposed to the ACA, claiming it supports a more purely market-based approach that expands access without imposing an individual mandate. Republicans have attempted to weaken the law and outright repeal it, but have stopped short of offering details on a substantive replacement. Opposition to the ACA remains steadfast among Congressional Republicans in the run-up to the election.

Democratic candidates for president, meanwhile, vary greatly in their approaches to healthcare policy. Former Vice President Joe Biden, still considered the front-runner in many states, supports the ACA and has said he would strengthen it and expand insurance access by adding a public option to the law -- pitting government-run insurance in the marketplace alongside offerings from private insurance companies.

While it may not be a shock that President Obama's former second-in-command would speak out in support of the ACA, other candidates' eagerness for a more radical overhaul of the healthcare system is a bit more surprising.

Perhaps no two candidates better represent the push for a more systemic shift than Sens. Bernie Sanders and Elizabeth Warren, who have called for a Medicare For All system that would expand the federal program to cover Americans of all ages, effectively rendering the private insurance industry obsolete.

Warren has been more cautious with her wording in recent campaign appearances, stressing the concept of "choice" in her healthcare plan and unveiling a transition roadmap that would furl out universal coverage gradually. Sanders has also released a potential roadmap, but remains more firmly committed to the idea of a government-run healthcare system.

Of all candidates in the Democratic field who have received national attention, it's entrepreneur Andrew Yang who has floated the most conservative healthcare plan. Yang's proposal eschews Medicare For All in favor of a plan that focuses more on lowering costs and expanding coverage. To do so, he introduced a six-prong approach. The six prongs: lowering prescription drug prices; investing in technology; expanding healthcare in rural areas; expanding access to mental health; offering flexibility to providers; and diminishing the influence of lobbyists.

Whether Trump wins re-election or is replaced by a Democratic contender, changes are likely coming to the healthcare system, and it's unclear where -- if anywhere -- the ACA will fit into the new paradigm.

BENEFITS

One of the advantages of a law surviving for this long is that it yields data that can be tracked over time. This data can provide a picture as to how effectively the law truly is, and based on a decade of research, the ACA has yielded mostly positive results, at least when it comes to insurance status and health outcomes.

One of the biggest benefits was reducing health disparities among racial and ethnic minorities. According to a May 2018 study published in JAMA Internal Medicine, after the ACA was passed, the rate of Asian Americans, Native Hawaiians and Pacific Islanders without health insurance dropped to 9%, a rate essentially equal to that of their Caucasian counterparts.

In 2009, the Veterans Health Administration, a part of the Department of Veterans Affairs, began implementing patient-centered medical homes on a national scale -- what's known as the Patient Aligned Care Team Initiative. In that year, all groups -- African Americans, Native Americans, Hispanics, Asians and Pacific Islanders -- lagged behind caucasians when it came to care quality. In 2014, the disparity for hypertension was similar for African Americans and improved only slightly for Hispanics, while multiracial individuals pulled even with whites. Native Americans and Pacific Islander experienced greater disparities over that time.

And in 2016, CMS released data highlighting the racial and ethnic disparities in patient experience and clinical care measures for Medicare Advantage beneficiaries. The data in disparity of care for eight patient experience measures showed that in seven areas, Asians and Pacific Islanders rated their experience in scores worse than that of whites, compared to five areas for Hispanics, three areas for blacks and only two areas for American Indians and Alaska natives. Patient experience measures included getting appointments and care quickly, getting needed prescription drugs and receiving flu vaccines.

Today, the Asian American and Pacific Islanders, collectively known as AANHPIs, is the fastest-growing racial and ethnic group in the U.S., encompassing more than 50 ethnicities and 100 languages, the authors said.

Another group that benefited from the ACA was people with diabetes.

In September, A research team analyzed information from 11 years of the National Health and Nutrition Examination Survey, which gathers data that's nationally representative of the civilian population. It found that in 2009 and 2010, 17% of adults who were under the age of 65 and had diabetes were uninsured. After the ACA took effect, that percentage declined by 12% -- and by 27% among those with low income.

Coverage gains were particularly strong among people whose diabetes was undiagnosed. In 2009 and 2010, about one in four adults under age 65 with undiagnosed diabetes lacked health insurance coverage. After the ACA was implemented, the uninsured rate in this group dropped by 17 percentage points, to 8%.

WHAT'S IN STORE IN 2020 AND BEYOND

The fate of the ACA is anyone's guess.

Texas Judge Reed O'Connor's controversial decision striking down the Affordable Care Act this month is only the beginning of what is expected to be a lengthy legal and political process.

The plaintiffs who won the case are 20 Republican-led states which brought a lawsuit in February claiming that the individual mandate is the core provision of the ACA and inseparable from the rest of the law. Without it -- as will be the case starting January 1 -- the rest of the ACA is unconstitutional, they said.

Following the decision, Democratic attorneys general, led by California Attorney General Xavier Becerra, filed a motion to allow for an immediate appeal of his ruling to the Fifth Circuit Court of Appeals in Texas, and asked O'Connor to stay his decision.

They also want the judge to clarify that the ruling does not alter consumer rights and state obligations under the ACA, until the matter is fully decided through appeal. Ranking Democrats have already said they would appeal, and a Democratic-led House of Representatives will also likely join the lawsuit.

Legal experts seem to agree that if the Fifth Circuit Court of Appeals upholds the decision, the case will likely head to the Supreme Court. The issue could become central to the 2020 election as it could take that long for the Justices to hear the case.

But if the appeals court reverses the order, the matter is not so clear.  Some legal experts expect the Justices would turn down the case.

It's also possible that Congress will pass a law solidifying the marketplaces and in a sense, render the legal ruling moot through legislative action.

Either way, Republicans are left in the defensive position of supporting the outright repeal of the ACA, including the provision for pre-existing conditions they promised to keep in place.

The Supreme Court has twice upheld the law. An earlier decision defended the validity of the Affordable Care Act as a form of taxation due to the individual mandate. This has now proved problematic, as the Texas court has ruled the ACA is invalid without the mandate.
 

Twitter: @JELagasse

Email the writer: jeff.lagasse@himssmedia.com