By Julie Rovner
Kaiser Health News
Nearly six years after its enactment, the Affordable Care Act remains a hot-button issue in the presidential race — in both parties.
“Our health care is a horror show,” said GOP candidate Donald Trump at the Republican debate in South Carolina Dec 15. Texas Sen. Ted Cruz, winner of the Iowa caucuses, said at the debate in Des Moines Jan. 28 that the health law has been “a disaster. It is the biggest job-killer in our country.”
Democrats largely support the law, but even they can’t agree on how to fix its problems. Hillary Clinton said at the Jan. 25 town hall on CNN that she wants to “build on the ACA. Get costs down, but improve it, get to 100 percent coverage.”
Clinton’s rival for the nomination, Vermont Sen. Bernie Sanders, acknowledged that “the Affordable Care Act has done a lot of good things,” but added that “the United States today is the only major country on earth that doesn’t guarantee health care to all people as a right.” Sanders is pushing a government-run “Medicare for All” plan instead.
In some cases candidates are bending the truth. But in general, both praise and criticisms of the law are accurate. That’s because the health law is so big and sweeping that it has had effects both positive and negative.
Here is a brief guide to some things the health law has — and has not — accomplished since it was signed by President Barack Obama in 2010.
CLAIM: The law has increased the number of people with health insurance coverage.
This is true, no matter what measure you use. The official Census Bureau and polling firm Gallup both found substantial drops in the percentage of people without health insurance after the majority of the law’s coverage expansions took effect in 2014.
COUNTER-CLAIM: There are still millions of Americans who don’t have insurance.
This is also true. Even though approximately 90 percent of Americans now have insurance, that remaining 10 percent amounts to more than 30 million people.
Millions aren’t eligible for coverage under the law because they’re not in the U.S. legally. Another 3 million are in the so-called “Medicaid gap,” meaning they would be eligible for Medicaid under the ACA except their states opted not to accept the expansion after the Supreme Court effectively ruled the expansion optional.
Still others are eligible to purchase coverage on a health insurance exchange but either can’t afford it, don’t think the insurance available offers a good value or don’t know they are legally required to obtain it. An estimated 7.5 million Americans paid a fine to the IRS for failing to get covered in 2014; millions more were exempt from the requirement and didn’t have coverage.
In recognition of the fact that enrollment has been smaller than expected, the Congressional Budget Office recently lowered its projections for those who will buy insurance under the law from 21 million to 13 million in 2016.
CLAIM: The ACA has fixed the dysfunctional individual insurance market.
Prior to the passage of the health law, millions of people who did not have work-based or government coverage were shut out of buying their own insurance because they had been sick or because the coverage offered did not cover the services they needed.
The law aimed to address the problems in the individual market in several ways, including requiring insurers to sell to those with preexisting conditions at the same price as healthier people; standardizing the benefits package; and limiting the size of deductibles. Tax credits were made available in order to help people afford coverage. And the law created insurance exchanges intended to help consumers compare, choose, sign up and pay for health insurance.
How well these changes succeeded in stabilizing the market is not yet clear. What is clear is that more people are now insured through the market.
COUNTER-CLAIM: The ACA has made the individual market worse.
All is not well in the reformed individual market.
Even with help paying premiums, many moderate-income Americans are finding that their deductibles and copayments are so high they cannot afford to use their insurance.
In other cases, individuals can get insurance they can afford to use, but it does not include their regular doctors and hospitals. In fact, plans that do offer coverage outside of the insurer’s network are becoming harder to find and more expensive.
That change affected Cruz, who initially claimed his private insurance had been cancelled. In fact, his insurer had stopped offering his broad-choice plan and automatically transferred him to a narrow-network product.
CLAIM: The ACA has improved the Medicare program.
While most of the law was aimed at those without insurance, lawmakers also took the opportunity to beef up some benefits for the 55 million Americans in the Medicare program.
Medicare enrollees got new coverage for preventive services and annual checkups, and those with high prescription drug expenses got help to fill the “doughnut hole” gap left by the 2003 Medicare drug program.
Over the longer term, the law created several payment experiments intended to improve the quality of care Medicare patients receive and lower costs. These include efforts to prevent patients from going back to the hospital after they’ve been discharged.
COUNTER-CLAIM: The ACA has not saved money for Medicare.
The rate of increase in Medicare spending has slowed since the health law was passed in 2010. But it’s not clear how much of that can be attributed to the law, aside from some provisions that actually cut payments to hospitals and other health providers.
And some of the most highly anticipated projects, including “accountable care organizations” that are paid bonuses for keeping Medicare patients healthy and lowering spending, have not so far shown very good results.
CLAIM: The ACA has killed jobs.
One of Republicans’ favorite talking points — that the health law would depress employment, particularly full-time employment — has turned out not to be the case.
An analysis in 2015 by the Urban Institute found that the health law “had virtually no adverse effect on labor force participation; employment; the probability of part-time work; and hours worked per week by nonelderly adults.”
While there would be fewer people in the workforce due to the law, the Congressional Budget Office found in 2014 that “almost entirely” stems from voluntary actions by workers who could quit because they no longer depended on their jobs for insurance — now they could buy it on their own.
CLAIM: The ACA has slowed overall health spending.
The White House trumpeted the fact that health spending grew at its slowest rates ever between 2010 and 2013. But health policy analysts are still engaged in a lively debate about how much of the slowdown was attributable to the recession, to the health law and to other changes in the health care system.
Meanwhile, the rate of spending has begun to accelerate again, jumping from a 2.9 percent increase in 2013 to 5.3 percent in 2014. That has occurred as millions more Americans gained access to health care through the law.
This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.