The Affordable Care Act: A Look Back

Ten years ago this month, the major parts of the Affordable Care Act (ACA) became effective. Two of the biggest were the availability of healthcare coverage through Medicaid expansion for low-income adults — in states like Arkansas that chose this option — and financial assistance to purchase coverage through the health insurance marketplace for the many who fell in the gap between Medicaid eligibility and job-based insurance.

Those two parts of the ACA have had a major impact on Arkansans’ lives. Medicaid expansion, which Arkansas accomplished through a premium assistance model originally called the Health Care Independence Program and now called Arkansas Health and Opportunity for Me, has served over 718,500 Arkansans over the life of the program. Health insurance marketplace enrollment among Arkansans reached an all-time high in November at more than 119,000, with 9 out of 10 receiving financial assistance to cover some or all of the premium.

High-level data points are powerful for describing the scope of the impact of the ACA, but just as meaningful is how different the health insurance products and buying experience are for the individual consumer due to the protections in the law. With the passage of a decade’s time, we sometimes forget, so let’s take a stroll down memory lane.

The year is 2009. You are a single mom of a 10-year-old dependent. You are employed at a large retail clothing store that does not offer insurance coverage as a benefit. Your income is too high to qualify your household for Medicaid coverage, and neither you nor your child meets any other conditions for eligibility. You desperately need to buy insurance, because you have a heart condition and your child has behavioral health needs that are costly to manage.

You apply for health insurance coverage with multiple companies online, but there’s no single, convenient location to compare the plans’ benefits, quality, costs, or provider networks in a standardized way. This is disappointing, since just last week you were able to easily compare hotel features and costs for an upcoming stay.

You feel confident in understanding healthcare lingo after having helped your dad navigate a long stint in the hospital a few months ago, but the language describing the plans’ benefits and exclusions is baffling, making it difficult for even the most health-literate to make an informed decision. From what you can gather about each of the plans, the benefits vary greatly. None has pregnancy coverage. Only a couple offer the behavioral health benefits essential for your child, and very few offer preventive benefits like cancer screenings with no out-of-pocket costs.

All of the plans that are affordable and offer the benefits you need have an annual and lifetime cap on what the insurer will pay for your medical costs. You worry that if you or your child experiences a severe illness resulting in a long hospital stay like your dad, the costs might exceed that cap, leaving you responsible for the excess amount.

The applications are long, too. They ask all sorts of questions about conditions that you and your child have or have been told you have, whether you are or are planning to get pregnant, and the medical history of your parents and grandparents. If you are untruthful about your and your child’s pre-existing conditions, the insurance company might deny treatment for those conditions. If you are truthful about those pre-existing conditions or plans for another child, they might deny your application outright, or make the coverage so costly that it becomes unaffordable.

Now jump ahead to 2024. The ACA has addressed many of the challenges experienced in our 2009 scenario.  It created the health insurance marketplace, offering a one-stop-shop for plan comparison. It advanced health literacy and patient-centeredness, requiring information about insurance plans on the marketplace to be presented in a consumer-friendly and culturally and linguistically appropriate fashion. It required plans to offer a standard set of 10 essential health benefits, including preventive services with no out-of-pocket costs, pregnancy care and behavioral health services. It prohibited insurers from placing annual or lifetime caps on what they would pay for medical costs, and perhaps most notably, it prohibited insurers from denying or increasing the cost of coverage based on pre-existing conditions.

There are always tradeoffs, and many will acknowledge that we still have a long way to go in addressing the quality and cost of care in our healthcare system. However, as we look back over the last decade, it is evident that the consumer protections in the ACA and the wise decision of our state policymakers to opt for Medicaid expansion under the ACA have advanced the level of access for Arkansans who struggled to obtain affordable healthcare coverage. As it turns out, that’s pretty popular, making it very unlikely for our single mom to go through her 2009 experience again.

Editor’s note: Craig Wilson, J.D., M.P.A., is the director of health policy for the Arkansas Center for Health Improvement, an independent, nonpartisan health policy center in Little Rock. The opinions expressed are those of the author.