This year, Americans’ access to health care took the spotlight like never before.
During the presidential campaign, both President Donald Trump and President-elect Joe Biden promised much to address these health and economic issues, sparring on how best to provide Americans access to health care. Central to both of their arguments remained a decade-old law: the Affordable Care Act, landmark health care legislation that showed its continued significance during this particularly difficult year.
Trump wanted to dismantle it, while consistently promising a replacement plan that never materialized, and Biden promised to build on the current law with hopes of offering a public option.
“Health care is the kitchen table issue for most Americans, both because of cost and because of what it means to go through life without coverage,” said Leslie Dach, a former senior counselor at the Department of Health and Human Services during the Obama administration.
“We are now at a time this year when people needed the ACA more than ever, and years of studies have shown how its coverage has positive impact on people’s health, life expectancy and the ability to get a job,” added Dach, the founder of Protect Our Care, a liberal group aimed at protecting the law. “And yet for purely partisan or ideological reasons, people are trying to take it apart.”
Those efforts haven’t been particularly fruitful.
‘A big safety net during the pandemic’
A little more than 10 years after the law known as Obamacare was passed, the landmark health care legislation has survived numerous attacks under the Trump administration and appears to be deeply embedded in the nation’s health care system. The effect it has had during this difficult year — whether in politics, policy or at the kitchen table — is hard to dispute.
Though it is currently difficult to know exactly how many people remain without their health insurance because of the current economic crisis, between February and June approximately 14.6 million people — workers and their dependents — were affected by job losses that also resulted in losing employer-sponsored health insurance, an estimate by the Commonwealth Fund concluded.
In states that passed Medicaid expansion, the Affordable Care Act helped shore up some of those losses, particularly as rolls for the public health insurance option for low-income people have ballooned this year.
Other people have found options through the plans offered by the ACA or received coverage from a spouse or parent, COBRA, short-term health plans or just gone without.
The exact number of people who lost insurance in 2020 will remain unknown until late next year. The Congressional Budget Office released a report in September looking at the amount of people who were uninsured in 2019 — 30 million — and estimated the number could jump by 1 million people because of the pandemic.
It concluded, however, that the situation may have been worse if not for the options offered through the ACA and the ways the law expanded Medicaid.
“In a lot of states, it didn’t matter how poor you were or how much income you lost, you still might not have qualified for Medicaid before the ACA existed,” said Cynthia Cox, the vice president of the Kaiser Family Foundation and director of its ACA program. “So the Medicaid program has been a big safety net during the pandemic and its economic turmoil and everything that’s occurred as a result.”
The law has also appeared to remain quite durable, despite it effectively losing the individual mandate, which required all Americans to sign up for health insurance or face a costly tax penalty. Trump used a 2017 tax bill to make the penalty for violating the individual mandate $0.
The Supreme Court could still decide to strike down part or all of the law next year, but many believe that is unlikely after justices listened to oral arguments earlier this month.
It appears Trump will exit office without fulfilling his promise to “repeal and replace” — or even just “repeal” — Obamacare.
The reason the law was impossible or extremely difficult to dismantle, many experts said, is because it is so deeply baked within the American health care system. So much so that it would be difficult for consumers and insurers to imagine the health care landscape after it was gone.
“Everyone talks about Obamacare as if it's a thing, an object, like you can point to the Obamacare part of the federal government or federal budget, but it’s not like that,” said Chris Pope, a senior fellow focused on the ACA and entitlement reform at the Manhattan Institute, a conservative think tank. “The Affordable Care Act tinkered with federal statutes in a 1,000 different places, many of which have since changed. There are new laws that depend on it. So you can’t just strike it down.”
The law has also hit its peak popularity this year since its passage in 2010 with 55 percent of Americans saying they view the ACA favorably, according to the Kaiser Family Foundation. Experts credit the growing favorability to Trump’s threat of removing it without a clear plan to replace it.
Trump attempted to damage the law by cutting the marketing budget for open enrollment and outreach by 90 percent, according to the Kaiser Family Foundation.
Cox said many may not know they are currently eligible for health insurance through the ACA as a result, or that they can currently sign up for coverage until Dec. 15.
“Four out of 10 uninsured people are eligible for free coverage, either Medicaid or a zero-premium bronze plan,” she said, referring to a plan offered through the ACA. “So there's a very good chance that people who are uninsured now could actually be getting covered for free. But they would need to act quickly.”
Is ‘Bidencare’ next?
Biden said he has big plans to build on top of the law so others can gain access to health care. It may be a challenge for him to do much in Congress, however, as both chambers face small margins in either direction for party control.
While the former vice president said he planned to roll out a public option that he has called “Bidencare,” few believe that he will be able to convince Republicans to buy into a plan like that.
It is more likely he will instead try to undo some of the Trump administration’s efforts to undercut the ACA while also looking at ways to entice the dozen states that have refused to expand Medicaid.
The impasse is chiefly due to Republican-controlled state governments that declined the largely free federal funding to expand Medicaid for ideological reasons around fiscal spending and because of its connection to the Obama administration.
But Benjamin Sommers, a professor of health policy and economics at the Harvard T.H. Chan School of Public Health, said these states are forgoing an economic boon offered by the federal government.
States did not have to cut any programs and saw huge amounts of economic benefit when they decided to expand, he concluded in a June analysis published in the New England Journal of Medicine.
“It's a win for the state budget and clearly for the patients,” he said. “And when you take all that together, what you can see is that Medicaid is not only a public health investment during a pandemic, but it’s also a form of stimulus for the local and state economies.”
While 12 states continue to refuse Medicaid expansion that would likely provide health insurance to 2 million people, voters in Missouri and Oklahoma — both considered conservative states — elected to take on the option via ballot initiative this year, appearing to prove that elements of the ACA are universally popular.
Download the NBC News app for breaking news and politics
Biden is expected to try to find ways to encourage the remaining 12 states to sign on to the expansion, which would largely benefit members of the working poor, but it could take some time.
Pope said it is inevitable that the states will sign up eventually. He noted that it took nearly 20 years for all states to adopt Medicaid after Lyndon B. Johnson signed it into law as part of his War on Poverty.
“From a state point of view, it's a pretty good deal,” Pope said. “They get $9 from the federal government for every dollar they spend themselves. So I think everyone kind of assumes that they'll eventually take it, but the question is: To what extent will the Democratic House, the Biden administration and an evenly divided Senate put some extra money on the table to move the needle in that direction?”