Affordable Care Act 2010: Coverage Expansion Explained

Legislative History and Political Context

When the Affordable Care Act (ACA) was signed into law by President Barack Obama in March 2010, the legislative process was saturated with tension and heated rhetoric. After a bitter, chaotic period in which legislators attempted to hold town hall meetings to explain the benefits of the plan — and organized disruptions at those meetings set a nasty tone — it squeaked through the U.S. Congress with hardly a vote to spare. It received no votes from Republican members of the House of Representatives and barely passed the House (219–212), with all 178 Republicans voting "no." Not one Republican in the U.S. Senate supported the ACA; the vote was 60 Democrats to 39 Republicans.

Why was this healthcare legislation so unpopular with conservatives? The answer is many-faceted, and likely boils down to the fact that Obama was the one pushing the legislation — derided by opponents as "Obamacare." Anything Obama proposed throughout the first three years of his administration was attacked and rejected by Republicans, the Tea Party, and independent conservatives. Moreover, according to the opposing forces, this was a "government takeover" that would create "death panels" to decide whether elderly patients should receive treatment.

Unfortunately, the ACA became law in a toxic political environment — an environment made even more antagonistic by the daily drumbeat of smears and vicious attacks from right-wing talk radio hosts. Despite the controversy, 32.5 million Medicare recipients had received free preventative screening services and 54 million Americans had gained coverage for preventative services (White House) by the time the bill awaited a Supreme Court ruling on its constitutionality.

A key policy component within the ACA that was often overlooked amid the unending attacks on the legislation is the mandate to expand healthcare services to more people in more ways. According to the White House, the ACA provides "a more secure future" for many Americans.

Key Coverage Mandates of the ACA

The expansion of healthcare insurance and services includes the following provisions: (a) Young adults can remain on their parents' health insurance plan until age 26. (b) Previously, people with pre-existing conditions were limited in how long they could receive benefits from insurance companies; by 2014, there could be no limits on coverage by insurers. (c) Businesses have an easier time finding better plans to provide coverage for more of their employees. (d) Insurance exchanges became part of the ACA in 2012, helping those lacking choices to obtain coverage and adding more people to the rolls of the insured. (e) By 2014, people with disabilities — many of whom were previously locked out of healthcare insurance because of pre-existing conditions — could not be turned down for coverage. (f) All new health insurance plans must cover preventative services such as mammograms and vaccinations, giving more people access to preventative care. (g) By 2014, all Americans would be required to have health insurance — a controversial provision, but one seen as pivotal to the success of insurance exchanges and expected to add millions to the insured population (White House).

Writing in the peer-reviewed National Tax Journal, Jonathan Gruber explains the rationale that drove the Obama administration to push the Affordable Care Act through Congress. Among the key factors he identifies: (a) the U.S. spends 17% of its gross domestic product on healthcare, "by far the most of any nation in the world"; (b) healthcare spending is "rapidly outstripping the rate of growth of our economy"; (c) the infant mortality rate for white Americans is 0.57%, but for African Americans it is "more than twice as high at 1.35%," a disparity attributable in part to the fact that the U.S. is "the only major industrialized nation without universal access to health care"; and (d) one in five non-elderly citizens — roughly 50 million people — do not have health insurance (Gruber, 2011, p. 893).

Stephen H. Gorin, a professor of Social Work, has published an editorial in the peer-reviewed journal Health & Social Work in which he claims the ACA "provides a crucial framework for addressing the critical health care issues facing our country, particularly in the areas of coverage and cost" (Gorin, 2011, p. 83). Gorin quotes the National Association of Social Workers (NASW), which called the ACA "a monumental piece of legislative achievement of our time" and "a significant step forward toward a comprehensive and universal health care system for our nation" (Gorin, p. 83).

With respect to the expansion of coverage, Gorin (p. 84) identifies several specific mechanisms. First, funds are already being provided by the federal government for "high-risk pools" — pre-existing condition insurance plans — for people who cannot obtain coverage because of prior health conditions. Second, adult children can remain on their parents' plan until age 26. Third, Medicaid will be available to any person under 65 whose income falls below 133% of the federal poverty line. Fourth, the insurance exchange program allows people without employer-sponsored insurance — and small businesses — to obtain good coverage at fair prices.

Peer-Reviewed Analysis of Expanded Services

Fifth, the mandate that everyone have insurance by 2014 is central to the law's design. Gorin notes that while the Supreme Court might strike down the individual mandate, without it "many individuals would wait to purchase health insurance until they needed care" (p. 84).

Lawrence R. Jacobs, writing in the peer-reviewed Journal of Health Politics, Policy and Law, predicts that the ACA will "give rise" to new patterns — most notably a "shift in policy from distributing health insurance according to the ability to pay and obtain generous employer coverage to extending health insurance as a social right by redistributing resources from the affluent and healthy" (Jacobs, 2011, p. 625). The key phrase in Jacobs' assertion is "social right": once health insurance is recognized as such, it will be greatly expanded to cover most adults in America. For those who cannot afford to purchase insurance — notwithstanding the mandatory requirement — the government commits to providing "subsidies to low- and middle-income individuals and small businesses to purchase insurance" (Jacobs, p. 626).

The one policy component in the ACA that most directly assures the expansion of health insurance coverage is the mandate that every American must be insured. Some 32 million Americans are expected to gain coverage as a result (Gorin, p. 85).

According to Gorin, the "father" of the individual mandate is Mark Pauly, an economist. Pauly explained that he and his colleagues proposed the individual mandate because they were "concerned about the specter of single-payer insurance, which isn't market-oriented, and we didn't think was a good idea" (Gorin, p. 84). In a Q&A published by Knowledge @ Wharton, an online scholarly business journal, Pauly elaborated on his reasoning:

"Unlike me, [most people] don't get up every morning and think about health insurance. They think they're healthy, and why buy insurance if you're healthy? There's also the view that, well, if I get really sick, no one's going to leave me bleeding in the street. In fact, federal law requires you to be treated at an emergency room and stabilized, regardless of your ability to pay. So in a way, people will rely on the charity of others to compensate for the fact that they don't have insurance… it's still a terribly bad idea to run around without health insurance no matter what you are and no matter how much you count on charity… we thought it was important to have a mandate to kind of round up the stragglers" (Pauly).

Conclusion

Jacobs, Lawrence R. (2011). America's critical juncture: The Affordable Care Act and its reverberations. Journal of Health Politics, Policy and Law, 36(3), 625–633.

Roy, Avik. (2012). The tortuous history of conservatives and the individual mandate. Forbes. Retrieved June 5, 2012, from http://www.forbes.com

The White House. (2012). 5 important numbers on health reform. Retrieved June 6, 2012, from http://www.whitehouse.gov