Q014 The part of the Affordable Care Act that was eliminated by Congress in 2022 was

Editor’s Note: This post is part of the Health Affairs Blog short series, “The ACA at 10: Health Care Revolution,” published with support from the Solomon Center for Health Law and Policy at Yale Law School and the Healthcare Transformation Institute at the University of Pennsylvania’s Perelman School of Medicine, Department of Medical Ethics & Health Policy. The authors of the posts in the series are featured, along with others, in the book The Trillion Dollar Revolution, edited by Abbe Gluck of the Solomon Center and Ezekiel Emanuel of Healthcare Transformation Institute, and many of them were featured in a conference last year cosponsored by the two organizations. (Check out also the Health Affairs theme issue, "The Affordable Care Act Turns 10," released March 2, and register for the March 10 issue briefing.)

President Barack Obama called the 2010 midterm elections a “shellacking.” He was right. Democrats lost 64 seats in the House of Representatives, relinquishing a majority they had won just 4 years before. And although the results reflected a variety of factors, they had a lot to do with anger over the Affordable Care Act (ACA).

Republicans had spent the campaign attacking “Obamacare” as a boondoggle that would make private insurance more expensive, undermine Medicare for seniors, and generally wreck everything that was good about the US health care system. With the messy, year-long effort to pass the law still a fresh memory, voters seemed inclined to agree. Public opinion tilted toward disapproval of the law by anywhere from a few percentage points to more than 10, depending on the survey. One study by a group of prominent political scientists concluded that the health care law had cost the Democrats about 25 seats.

Eight years later, in the 2018 midterm elections, it was time for another shellacking. But this time it was the Republicans losing dozens of House seats, thanks in part to anger over their repeal effort. Public opinion had shifted in favor of the law and the campaign played out as a near-perfect reversal of 2010. More than half of Democratic ads focused on health care, according to one assessment, and it was a dominant theme of their speeches as well. Republicans reacted either by trying to dodge the subject, as many Democrats in 2010 had, or trying to obscure their records—in particular, by insisting that their repeal votes did not mean they had tried to take away the law’s popular features, like protections for people with preexisting conditions. (Among the Republican candidates making these claims were Senate candidates Martha McSally (AZ) and Josh Hawley (MO) and House candidates Mike Bishop (MI) and John Faso (NY).)

Not that vindication of the ACA was total. The number of Americans expressing disapproval of the law may have ceased to be a plurality, but they still represented a substantial portion of the country. And that remains the case today. One reason is that millions still struggle with medical bills, sometimes because they remain uninsured and sometimes because the insurance they have costs too much or covers too little. But for all its well-documented flaws, the ACA has clearly provided the public with something that it values. That is no small thing.

The Democrats Succeed—At a Cost

Change in American politics is difficult. These days it is especially difficult for progressives, for a combination of reasons that include the disproportionate representation of small states in the Senate (which happens to favor Republicans) and the influence of money in politics (which generally fights redistribution of any kind). Health care interests are a particularly powerful group, and it’s not just the insurance and drug industries that fight to preserve their revenue streams. It’s also the hospitals and doctors and other care providers.

As for the public, it’s unhappy with the status quo but skittish about change. It is all part of a phenomenon that political scientists call “path dependence,” and it helps explain why transforming health care stymied so many would-be reformers over the years.

Obama and his allies were determined to overcome these obstacles. They adopted a scheme heavily reliant on private insurance, cut deals with health care industry groups, and decided to leave employer-sponsored coverage largely as it was. These and other decisions had a substantive rationale, a political logic, or both, depending on who was making the case for it. Democrats pledged that reform would be budget-neutral, for example, partly because some officials thought it was the right thing to do and partly because others thought it was necessary to keep more conservative Democratic lawmakers on board while, ideally, luring a few Republicans, too.

Each one of these decisions entailed tradeoffs that help explain the skepticism and hostility that the ACA has generated for most of its legislative life. The extended negotiations with Republicans turned the proposal into a punching bag for opponents—never more clearly than in August 2009, when Tea Party protesters first descended upon Democratic lawmakers back in their districts. That anger only grew as the process dragged on, in no small part because concessions Democrats had made to get the 60 Senate votes needed to overcome a filibuster, like dropping a public insurance option, had disheartened their supporters.

The Republicans Fight—And Nearly Win

Between 2010 and 2016 House Republicans passed repeal bills more than 50 times. Although the votes felt largely symbolic, given that the GOP did not control the Senate until 2015 and did not control the White House until 2017, those votes were part of a broader campaign to undermine the law.

The most consequential element of that campaign was, arguably, the actions by GOP state officials who refused to expand their Medicaid programs as the law’s architects had hoped. They could do so because of leeway the Supreme Court had given them in the first of two major challenges to the law. With the federal government picking up nearly all the cost, several Republican governors embraced expansion. But in states like Florida, Georgia, and Texas, GOP officials held out and millions of low-income people consequently remained uninsured.

In Washington DC, determined Republicans targeted the ACA’s risk corridor program, which was designed to insulate insurers from excessive losses. Conservatives called it as an insurer “bailout,” even though a similar program existed in Medicare Part D without controversy; in late 2015, they secured a provision inside a year-end spending agreement to mostly eliminate the program’s funding. In subsequent years, with payouts from the program a pittance of what the government had promised, insurers had to jack up prices, and some smaller carriers had to shut down altogether.

Those problems did not help the ACA’s public image, although frustration with the law also had a lot to do with its design and function. In 2014, when the law took full effect, insurers canceled old plans (despite Obama’s promise that people could keep their plans if they liked them) and charged higher premiums for the new ones because now they had to offer more benefits and cover people with preexisting conditions. Both of those things cost money. The ACA’s subsidies offset the premium increases for many but not all consumers. In the years that followed, insurers in many states had to raise premiums substantially or abandon markets altogether.

Subsequent research found that the number of people who actually lost plans because of the ACA was relatively small. One reliable estimate put the figure at 2.6 million—a substantial number of people in absolute terms but a tiny portion of the population. Many of those who lost plans ultimately found cheaper plans, while even those spending more usually got coverage with more benefits and protections for preexisting conditions that their old plans had lacked. But especially in an era of intense party polarization, vast swaths of Americans took their cues from partisan leaders, with intensity predominantly on the Republican side as Democrats qualified their support with acknowledgement that more needed to be done.

Repeal (Mostly) Fails And The Law (Mostly) Survives

President Donald Trump’s 2016 victory seemed to make repeal inevitable. But Trump and his allies had made vows they could not keep.

Republicans had promised an alternative that would provide better coverage to as many or more people for less money. The most audacious claims came directly from Trump, who vowed that “we’re going to have insurance for everybody,” that “everybody’s going to be taken care of much better than they’re taken care of now.” Once he took office, his lieutenants echoed and amplified these statements, like when House Speaker Paul Ryan (R-WI) said that Republicans would make sure “no one is worse off.”

In reality, Republicans could not escape policy tradeoffs any more than Democrats could 10 years before. Health care is so expensive that the only way to make it affordable for everybody, at least in the short term, is to have the government spend a lot of money in the form of subsidies or direct provision of coverage. Any system that relies on private insurance, even in part, will require a lot of regulation because otherwise insurers will avoid covering expensive services and the people who are likely to need them.

Republicans, of course, were determined to reduce government spending and regulation. Doing so advanced longtime conservative goals, like shrinking government, which they believe benefit society by improving the economy and enhancing liberty. But such policies were bound to leave more people struggling with health care bills, as the Congressional Budget Office eventually determined in its assessments of GOP proposals.

This did not sit well with the public. Since the ACA’s enactment, millions had gotten coverage through the Medicaid expansion, funding for which Republicans were going to eliminate, or with the help of federal subsidies for private coverage, which Republicans proposed to redirect and shrink. Others had come to count upon guarantees of coverage for people with preexisting conditions, which Republicans proposed to undermine, albeit in roundabout ways.

Even at the nadirs of the ACA’s popularity, polls showed that most of the law’s elements were extremely popular, even with Republicans—just as the Medicaid expansion, long thought to be politically vulnerable, turned out to have deep reservoirs of support in some of the most politically conservative parts of the country. (One reason was Medicaid’s role in financing treatment for the opioid epidemic ravaging places like Ohio and West Virginia.)

The failure of repeal legislation did not end the Republican Party’s interest in eliminating the ACA. In the ensuing years, the Trump administration canceled funding for outreach, stopped paying a key set of subsidies for insurers, and rewrote regulations about the kind of insurance that private insurers could sell. It also changed the rules about how states could design their Medicaid programs. In late 2017, Congress passed a tax bill zeroing out the ACA’s penalty for people who did not carry insurance. Trump, who had supported the provision, signed it.

These efforts have not always succeeded or had the desired impact. But by 2019, the number of Americans without insurance was rising for the first time since the law’s enactment. Many experts believe Trump administration policies were a significant factor in that shift. Even the repeal threat lingers. Another legal challenge is working its way through the courts, while Republicans will likely revisit repeal if the 2020 elections restore their full control of the federal government.

Still, the ACA on its tenth anniversary seems to be as stable politically as government programs can be in this volatile era. Notwithstanding the real struggles so many people face in health care, and the debate over what to do next, GOP efforts at repeal have reinforced what the polls had said all along: Americans want to keep moving toward universal coverage, rather than away from it. The debates over Obamacare may never stop, just like the debates over health care policy will never stop. But they will never look quite the same either.