Compared to other high-income countries, the United States has repeatedly ranked low in every metric of healthcare- from access and quality to cost. Over 10 years ago, President Barack Obama alongside Vice President Joe Biden signed the Affordable Care Act (ACA) into action to combat some of these issues. After examining the effects of the ACA on American families and their overall health, it is apparent that there were both positive and negative attributes associated with the ACA--increasing access while increasing costs to others. Now with the Biden administration, we will see how healthcare under the ACA will expand and change in response to the lessons that we have learned over the past 10 years.
By examining metrics for healthcare access, we can analyze the effects of the ACA from 2010 to recently. The ACA was able to expand medical coverage to over 20 million additional Americans in 2016, which decreased the number of uninsured from 48.6 million in 2010 to 28.6 million in 2016 [1-3]. By raising federal poverty rates to 133% of normal rates, Medicaid has been expanded to almost 12 million new Americans in 2019 since its signing in 2010 . Along with government subsidies provided as premium tax credits for families up to 400% of federal poverty levels, insurance coverage increased dramatically for many Americans. Additionally, the ACA was able to establish the Healthcare Marketplace for Americans to search through private insurances rated from Bronze to Platinum. These “metal types” for health insurance categorize these plans based on deductibles, premiums, co-payments and other costs. Higher rated plans have more expensive monthly payments, but increased coverage and access to physicians and medical care.
In 2017, when the Trump administration transitioned into office, some changes were made to dilute the effects of the ACA. For example, the individual mandate, which fined individuals for not having insurance, was brought to $0. Additionally, the Trump administration brought certain legislation within the ACA to the Supreme Court in respect to the constitutionality of Congress to tax individuals without insurance. Preliminary studies have shown that the removal of the individual mandate will decentivize healthy, young workers from engaging with insurance . This finding decreases the chances of healthy Americans purchasing preventive care, while increasing their chances of expensive emergency care .
Furthermore, health insurance costs would rise as more sicker Americans are burdened with higher premiums. Overall, the actions of the Trump administration allowed young and healthy Americans to spend less on medical insurance while raising costs to those who have pre-existing conditions. However, although these changes were seen, the majority of the infrastructure created during the Obama administration remained during the Trump presidency- including the Healthcare Market, increased Medicaid coverage and legislation preventing insurances from discriminating against those with pre-existing conditions.
During Biden’s first year in office, multiple changes have already been proposed to the pre-existing ACA. One of the biggest changes that Biden has proposed is the introduction of a “Medicare-like” public option for general American citizens who are not eligible for Medicare or Medicaid . According to a 2020 poll conducted by Kaiser Family Foundation, 68% of American adults support a public healthcare option . A public option would most likely have lower premium costs, giving the federal government more negotiating prices to lower provider payment rates from private insurers. However, it is important to note the lobbying power of both the pharmaceutical industry and health insurance companies within a bipartisan Congress, and the lack of support President Biden would have for this public option.
It is unclear how healthcare plans will look under Biden’s administration because of recent COVID-19 stimulus packages and aid proposals. In particular, the $1.9 trillion stimulus package included money for mental health programs, subsidizing Medicaid eligibility criteria for those who are uninsured or on the individual market, supporting COVID-19 vaccination and testing programs and more . Under the Biden campaign, cutting costs and expanding costs were at the core of his political agenda on the topic of healthcare . For example, Biden is targeting subsidies to “Gold” health plans under the ACA marketplace exchange, thereby reducing premium costs. For families who are under 400% of the federal poverty line, Biden plans on capping the amount Americans spend on health insurance to 8.5% of their income . Regarding pharmaceuticals, Biden proposes to reduce pharmaceutical drug prices by enforcing a rebate on companies that charge drug prices higher than the rate of inflation . These proposals all seem to encompass Biden’s overall plan to decrease costs of healthcare spending for Americans.
These proposals also seem to align with strengthening the legislation of the ACA to expand coverage. It is important to note, however, that during the Obama administration, that costs generally increased for the general American population, which was an unintended consequence. This is evident through deductible increases from $217 in 2011 for the average enrollee in the individual market, to $515 in 2019, which is a 137% increase . With COVID-19 stimulus packages and vaccination programs continuing to impact the general public, it is unclear whether these health insurance programs promised by Biden during his campaign are feasible to pass under Congress in the coming months. However, through the stimulus package passed by Biden, it is clear that there is a considerable movement towards expanding Medicaid and increasing government subsidies to increase healthcare access within the ACA.
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