In Summary:

• The Affordable Care Act (ACA) has survived a third existential challenge in the U.S. Supreme Court
• A decade of evidence suggests that the ACA, while imperfect and incomplete, has been widely beneficial and grown in popularity 
• Finally moving past arguments over the ACA could open up new opportunities to advance state and federal health policy

Since its enactment in 2010, the Affordable Care Act has become a frequent visitor to the U.S. Supreme Court. With a June 17^th opinion that completely dismissed the latest challenge brought by California v. Texas, the nation’s highest court has held up the ACA as the law of the land. After surviving three major existential challenges at the Supreme Court, as well as a Congress and presidential administration intent on repealing the law, hopefully now the ACA—and components thereof, such as Medicaid expansion—can move into a new era where any further policy discussions focus on addressing or improving upon specific shortcomings of the law.

Putting aside arguments over the ACA could open up new opportunities to advance health policy, enabling policymakers to both address shortcomings in the law and develop solutions for new or different problems that have emerged (or remain unaddressed) since its enactment—such as the continuously growing cost of health care.

Background

In 2017, the Citizens Research Council convened an expert panel to discuss Michigan’s experience with the ACA. Panelists agreed that the Patient Protection and Affordable Care Act meant patients were better protected, even if affordability remained elusive for some. Nonetheless, the ACA’s marketplaces and subsidies, Medicaid expansion, and other reforms have directly led to health insurance for around one in ten people in Michigan, as well as providing more comprehensive benefits and health care consumer protections for others.

The Research Council’s report on Medicaid expansion (i.e., the Healthy Michigan Plan) found that the program has been a particular success, not only reducing the number of uninsured Michiganders, but also reducing uncompensated care/bad debt in hospitals and other health facilities, yielding state budget savings, promoting better health, and providing broad economic benefits. The combined benefits to the entire state from the Affordable Care Act have been particularly noteworthy in rural northern Michigan, as well as in some urban centers like Detroit and Flint.

Even now, Michigan’s successful Medicaid expansion is attracting the attention of experts from other states. Unsurprisingly, success in early adopting states has convinced many holdout states to begin expansion of their Medicaid programs.

In this context, I discussed the latest legal challenge to the ACA back in November, the same day the Supreme Court heard oral arguments in California v. Texas. In short, the case hinged on the severability of the minimum-coverage provision (the so-called “individual mandate” and the related penalty removed by Congress in 2017) from the rest of the ACA. If rather than dismissing the case, the Court had found the provision to be unconstitutional absent the associated penalty, it would have then needed to determine if the vast and complex ACA could stand without the individual mandate. The Court had previously upheld the legality of this minimum-coverage provision in National Federation of Independent Business v. Sebelius.

In November, I predicted the court was likely to uphold the law and leave it mostly (if not entirely) intact; indeed, by deciding the plaintiffs did not experience any harms that would give them standing to challenge the law and dismissing the case, the ACA remains unchanged—and ostensibly unscathed. Enrollment in ACA programs has reached a record high. According to polling from the Kaiser Family Foundation, public support for the ACA is also at an all-time high. 

The Road Ahead

Despite achieving many successes and yielding numerous improvements to health care payment and service structures, the ACA clearly under-delivered on its titular promise of affordability. U.S. health care spending was growing at rates far in excess of inflation before the ACA’s enactment, and so it would be disingenuous to place the blame for excessive health care spending on the ACA. Nonetheless, despite the ACA’s various reforms, the nation continues to spend far more than other nations on health care with a greater number of uninsured individuals.

Partisan battles over the validity of the ACA have distracted from opportunities for further health care and/or health insurance reforms. In 2017, I wrote that policy discussions should focus on revising and repairing the ACA rather than give way to the symbolic, chest-thumping demands to repeal and replace the law. Four years later, that sentiment remains valid and applicable.

The U.S. health system has widespread (and expensive) flaws. Slogans and buzz words, like “Medicare for All” or “no socialized medicine” fail to capture the wide variety of ways that other nations achieve universal health insurance coverage and likewise fail to address the nuance and specificity needed to address various issues affecting America’s health. Unfortunately, the zeitgeist of bitter and volatile political divides, alongside diminished public trust, is not particularly conducive to nuance nor complexity.

Universal coverage is a unique economic challenge, influenced by our values and the way we distribute scarce goods and services; universal coverage is not dependent upon a single insurance or care delivery model, as other countries achieve universal coverage through singular public insurance (Canada), public health providers (UK), or multiple private insurance providers (Germany), to name just a few.

While the scope of insurance coverage affects cost, the cost of health care is perhaps better viewed as a separate policy problem, affected not only by the number of consumers (universal or partial coverage), but also the structure and cost of services on the supply side, and population health on the demand side (alongside other, complex factors). Supply-side factors can be addressed through a variety of policies and payment models; population health, while influenced by health care, is largely determined by the separate (in the U.S.) sphere of public health, in which we grossly underinvest.

With the fog of controversy surrounding the ACA hopefully in America’s rear-view mirror, it’s time to resume the drive for practical and sustainable health care reforms.