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12 Years Later:
The ACA Is Stronger Than Ever

Twelve years ago, the Affordable Care Act (ACA) became the law of the land and millions of Americans gained coverage and critical protections as a result. Thanks to the ACA, more than 30 million Americans have health coverage through the Marketplace and Medicaid expansion. Last year, President Biden signed the American Rescue Plan (ARP) into law, which builds on the strong foundation of the ACA by lowering premiums for middle and working class families, expanding coverage for millions who were previously uninsured, and increasing access to essential health services, like maternity care. 

After years of Republican efforts to repeal and sabotage the ACA, President Biden and Democrats in Congress have made historic investments to secure the future of American health care. Thanks to their vision and determination, 2022 saw 5.8 million Americans newly insured by an ACA plan and an additional 83 million Americans receiving their coverage through Medicaid or CHIP. Americans can now sleep easier at night knowing the ACA is here to stay and President Biden is hard at work to expand coverage, lower costs, and reduce racial disparities in health care.

Where U.S. Health Care Stands 12 Years After The Affordable Care Act: 

  • GAINED: Protections for over 135 million Americans with pre-existing conditions. 
  • GAINED: 19 million people are now covered thanks to Medicaid expansion. 
  • GAINED: 3.2 million Americans now have health coverage for less than $10 per month.
  • GAINED: 83 million Americans have coverage through Medicaid and CHIP.
  • GAINED: 2.3 million adult children are able to stay on their parents’ insurance. 
  • GAINED: Insurance companies are banned from charging women more for the same care as men.
  • GAINED: Key support for rural hospitals. 
  • GAINED: Ban on insurance companies having annual and lifetime caps on coverage.
  • GAINED: Requirements that insurance companies cover prescription drugs and maternity care.
  • GAINED: Improved access to care and financial security for families. 

A closer look at how the Affordable Care Act is working across the country:

More Than 30 Million Americans Have Affordable Health Coverage. Because of the ACA, more than 30 million Americans have health coverage through the Marketplace and Medicaid expansion. 

More Than 14.5 Million People Have Coverage Through The Individual Market. In 2021, 14.5 million people signed up for health coverage through an ACA Marketplace. This is the highest number of Americans to ever enroll in an Open Enrollment Period (OEP) and it is thanks to President Biden’s American Rescue Plan. Premium savings under the American Rescue Plan benefit all Americans, with families now saving an average of $2,400 a year on their health insurance premiums.

Protections For 135 Million Americans With Pre-Existing Conditions. Because of the ACA, insurers in the individual market can no longer drop or deny coverage, or charge you more because of a pre-existing condition. More than 135 million Americans have a pre-existing health condition. And without the ACA, millions of Americans who have contracted the COVID-19 would likely be deemed as having a pre-existing condition and be at the mercy of their insurance companies who could refuse to pay for needed care. 

Women No Longer Charged More Than Men. Because of the ACA, insurers can no longer charge women more than men for the same coverage, and insurers are now required to cover important health benefits like maternity care. Before the ACA, only 12 percent of individual market plans offered maternity care. The ACA established maternity coverage as one of the ten essential health benefits required on all new individual and small group policies. The American Rescue Plan created a pathway to coverage for pregnant Americans, allowing states to extend postpartum coverage under Medicaid from 60 days to 12 months following pregnancy. The United States has the highest rate of maternal mortality in the industrialized world, with 12 percent of maternal deaths occurring between six weeks and one year following delivery, after Medicaid coverage has ended.

Guarantee Coverage That Costs Less Than 8.5 Percent Of Income. The American Rescue Plan builds on the ACA by ensuring enrollees have the option to purchase health care for less than 8.5 percent of their income. Previously, families earning just above 400 percent of the federal poverty level spent an average of 15 percent of their incomes on health insurance. 

Make Coverage More Affordable For All Americans. The American Rescue Plan temporarily expanded the eligibility for premium tax credits above 400 percent of the federal poverty level — roughly $54,000 for a single person or $111,000 for a family of four. 

Eliminate Premiums For Low-Wage Workers. The American Rescue Plan eliminated premiums for Americans earning up to 150 percent of the federal poverty level (roughly $20,000 for a single person and $41,000 for a family of four) who buy their coverage on the Marketplace and for those receiving unemployment insurance due to the pandemic.

Ended Annual And Lifetime Limits. Because of the ACA, insurers can no longer put annual or lifetime limits on the care you receive.

Young Adults Can Stay On Their Parents’ Plan Until Age 26. Because of the ACA, roughly 2.3 million young adults have coverage because they can stay on their parents’ coverage until age 26.

Allowed States To Expand Medicaid. Because of the ACA, states can access additional federal money to expand Medicaid. 12.5 million Americans were able to enroll in Medicaid during the COVID-19 pandemic, bringing the total of individuals covered by Medicaid and CHIP to more than 83 million, or one in four Americans. As of December 2020, 14.8 million Americans were enrolled in Medicaid due to Medicaid expansion and an additional 4 million previously-eligible adults gained coverage under expansion due to enhanced outreach, streamlined processes, and increased federal funding under the ACA. Between February and November 2020, states that expanded their programs saw a 22 percent increase in Medicaid enrollment. Additional research has shown that Medicaid expansion states were better positioned to handle the economic fallout of the pandemic, with fewer residents becoming uninsured. 

Incentives To Expand Medicaid. The American Rescue Plan built on the ACA by providing robust financial incentives for the 12 states that have not implemented Medicaid expansion. An estimated four million uninsured adults could gain coverage if the remaining holdout states adopted expansion. Importantly, people of color make up nearly 60 percent of this group. Even after paying the cost of Medicaid expansion, these states would receive an additional $9.6 billion in new federal funding that they could use to offset spending in other state programs or budget shortfalls. According to estimates from the Kaiser Family Foundation, the 12 states that have not yet implemented Medicaid expansion would receive $16.4 billion thanks to the enhanced federal match rate under the American Rescue plan, while the total cost of Medicaid expansion in these states would only be $6.8 billion

Eliminating Barriers To Medicaid Access. President Biden understands that health care is a right, not a privilege. In 2021, he kept his promise to roll back discriminatory Medicaid work requirements that create unnecessary obstacles for low-income individuals seeking access to affordable, quality health coverage. The Centers for Medicaid and Medicare Services have repeatedly stated that the vast majority of Medicaid beneficiaries are employed, ill, or disabled. The Biden Administration’s quick action put a permanent stop to these requirements in 12 states that received waivers under the previous administration. 

Free Preventive Care. Because of the ACA, health plans must cover preventive services — like flu shots, cancer screenings, contraception, and mammograms – at no cost to consumers. This includes the 158 million Americans with employer coverage as of 2019. Importantly, the ACA requires plans to cover all vaccinations recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP), including vaccines for COVID-19.

Comprehensive Coverage. Because of the ACA, insurers have to cover what are known as “essential health benefits,” such as maternity care, prescription drugs, and substance and mental health. As it stands, ACA-compliant plans must cover COVID-19 testing, treatment, and hospitalization. 

Improved Access To Care And Financial Security. Between 2010 and 2018, the share of non-elderly adults with a problem paying a medical bill fell by 17 percent, the share who didn’t fill a prescription fell by 27 percent, the share who skipped a test or treatment fell by 24 percent, and the share who didn’t visit a provider when needing care fell by 19 percent.

Helping Increase Access To Employer-Sponsored Coverage. The Affordable Care Act’s individual and employer mandates are credited with helping increase rates of employer-sponsored health insurance. The Kaiser Family Foundation estimates that between 2013 and 2017, seven million more people gained employer coverage.

Key Support For Rural Hospitals. Through lower premiums and expanded Medicaid, the ACA has profoundly reduced uncompensated care costs, which are often the direct result of individuals who are un-or-underinsured. In states that have expanded Medicaid, the likelihood of falling into medical debt is 20 percent lower than in non-expansion states. Additionally, a 2018 National Bureau of Economic Research analysis found that Medicaid expansion led to a nearly $6 billion decline in unpaid medical bills and to higher credit scores. 

Reducing Racial Disparities. The ACA has helped reduce longstanding racial disparities in coverage rates, improving health care access for communities of color across the nation. The ACA’s premium savings and expansion of Medicaid helped lower the racial gap in accessing care. In 2013, the gap between Black and white Americans struggling to access care due to cost was 8.1 percent. Due to the ACA, that gap dropped to 4.7 percent by 2018. The same tread occurred for Hispanic and Latino individuals, with the gap decreasing from 12.7 percentage points in 2013 to 8.3 points in 2018. The percentage of people gaining health insurance under the ACA was higher for Hispanics and Latinos than for any other racial or ethnic group in the country. The ACA also cut uninsurance rates among Asian Americans by more than half. 

Coverage For Frontline Workers. Frontline workers, including health care workers, rely on the ACA for comprehensive, affordable care. Without the ACA’s protections for pre-existing conditions, health care workers could be discriminated against by their insurance companies for having contracted or even being exposed to coronavirus. Additionally, many workers deemed “essential” during the pandemic, such as grocery store employees, do not receive employer-based coverage and therefore stand to benefit from the ACA’s individual Marketplace coverage options and Medicaid expansion. Research has shown that the ACA helped half a million direct care workers gain coverage.

State-By-State Fact Sheets