The Affordable Care Act (ACA) was signed into law 16 years ago, and its defenders often point to a simple metric as evidence of success: roughly 20 million previously uninsured people were able to enroll in health care plans. That number is real, but it is incomplete and increasingly misleading. The ACA’s greatest achievement was in expanding the number of people who had insurance cards. But those cards came at a cost. For most people, insurance now doesn’t cover the care they need.
What the ACA expansion actually looks like
Let’s start with where those gains came from. The bulk of the expansion in coverage that the ACA drove was not in private insurance but in Medicaid. The law led to millions of healthy working-aged adults being allowed to sign up for a program that historically had served a much sicker, poorer and more medically-complex population. The improvements in health outcomes that ACA proponents claim are less about the medical care that was delivered than about simple math. When you add a younger, lower-risk group to any system, average outcomes will improve. Focusing on the people who gained insurance because of the ACA ignores what the law did to everyone else.
Having insurance no longer means being protected in any meaningful sense.
The ACA’s primary achievement wasn’t an expansion of coverage. It was a fundamental redesign of insurance. Through a variety of new requirements — medical loss ratios, standardized benefits and new actuarial rules — it constrained how plans could be structured and how expenses could be managed. Insurers didn’t eliminate those costs. They simply moved them, or more properly put, they passed them along to consumers. Premiums rose. Deductibles rose even faster. On top of that, the ACA drove other predictable responses that tightened access, from narrow networks to tightened prior authorization requirements. Having insurance no longer means being protected in any meaningful sense. The new normal ushered in by the ACA means coverage that only kicks in after members have already spent thousands of dollars above and beyond their premiums.
For many people, their insurance is not enough
Today, more than half of Americans with employer-sponsored insurance — approximately 90 million people — go through an entire year in which their insurance doesn’t pay for a single dollar of the care they actually use. They pay premiums every month, and then, when they seek care, they pay again, this time out of pocket. They have an insurance card. They do not have insurance-covered health care.
Insurance exists in the background, but coverage is more theoretical than real.
This is not a problem that is happening on the margins. It is now a common experience. Most care for working-age people happens outside the hospital: primary care visits, labs, imaging and outpatient procedures. For the majority of fully-insured Americans, that care is self-financed. Insurance exists in the background, but coverage is more theoretical than real.
Defenders of the ACA will argue that this is still “coverage” — that insurance still offers protection against catastrophic events. Even if that were true, that is not how the law was sold. The ACA mandated essential health benefits, not bare-bones catastrophic plans. Yet, millions of Americans don’t have access to the comprehensive coverage they pay so dearly for, or at least not until after they have spent substantial out-of-pocket sums — often thousands of dollars. On paper, the ACA promised expansive benefits and cost savings. In practice, it led to skyrocketing prices and care that was at best, delayed and often denied.
This was not an accident. The ACA’s structure made it an inevitability, and it was a redesign of the system that did not stay limited to the exchange. It reshaped the much larger, employer-sponsored insurance market for the worse. While the ACA added 20 million people to the ranks of the insured, it also led the way on the near-universal adoption of high-deductible plans — deductibles many members never meet in a given year — normalizing self-pay for more than half of the 165 million who were on employer-sponsored plans.