At 10 Years Old, the Affordable Care Act Is Aging Badly

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Another open season has come and gone in which eligible Americans could choose from a narrow array of federally subsidized health care plans under the Affordable Care Act.

Despite the ACA’s manifest gaps and failures, a recent poll from the left-leaning Kaiser Family Foundation found that a solid majority – 55% – of respondents have a favorable perception of the law. That result may be due in part to a feature of the law most have heard about and support: its ban on private insurers denying coverage for preexisting conditions.

The ACA is much more than that provision, however. By almost any measure, the law has fallen short of its objectives. It included features that proved unpopular or unsustainable, led to a decade-long court battle with—of all groups—an order of Catholic nuns devoted to the poor and it subsidized elective abortion without subscribers’ knowledge in violation of what the law plainly requires.

The ACA was modeled in part on a Massachusetts health plan that created a statewide exchange, or marketplace, offering a menu of plans individuals and families could choose from, with gradations of coverage and cost. The ACA contained a mandate, since nullified by Congress, that each individual and family have a plan in force year-round.

But a withering report earlier this year from The Heritage Foundation underscores just how far short the law has fallen.

The promise of the ACA was better coverage at lower cost. Everyone remembers President Barack Obama’s sober pledge that American families would enjoy $2,500 in annual savings on their premiums and be able to keep their doctors. The Heritage report shows, instead, that in just five years, from 2013 to 2018, the average monthly premium paid by an individual rose from $244 to $550 a month, a more than 125% increase.

At the same time, the mid-tier quality plan on the federal exchange saw its annual deductible rise by more than $1,000. Provider networks, in turn, typically shrank.

Putative innovations under the ACA fared no better. The year 2020 saw the end of multi-state plans. These were private plans sold on the marketplace by insurance companies under contract with the federal government that were supposed to attract more subscribers while lowering costs.

In addition, the federal Multi-State Plan Program was required to guarantee individuals and families both a pro-life option and an elective abortion option in the states where they existed.

But multi-state plans proved unpopular with insurance companies, as became embarrassingly apparent when the number of multi-state plans was reduced from 203 to two between 2017 and 2019, and finally nonexistent this year. Co-op plans seem headed for the same fate.

Today, most U.S. counties have only one or two exchange plans. These are the plans for which federal premium tax credits are available.

The tax credits mean that abortion coverage is being subsidized with tax dollars in many instances. Just how often this occurs has been a regular focus of Charlotte Lozier Institute and Family Research Council—this year joined by The Heritage Foundation.

What we found for the 2021 plan year continues to be disturbing.

There are 24 states, plus the District of Columbia, that allow elective abortion coverage. In total, these states offer 1,296 plans, and a full 69% of them—892 plans—cover elective abortion. Eight states fail to offer a single pro-life alternative insurance plan on the ACA marketplace, several of them due to state legislative mandates.

Fortunately, 26 states have exercised their option under the ACA to bar from their exchanges any plans that cover abortion beyond the limited exceptions under the Hyde Amendment—that is, in cases where the life of the mother is at risk, rape, or incest.

Now 10 years old, the Affordable Care Act needs to be revisited. It covers fewer than half the estimated 24 million people its authors estimated would be helped.

Rather than chase the Little Sisters of the Poor with mandates to provide no-cost coverage of contraceptives and abortifacients for their employees, Congress should apply the Hyde Amendment permanently and pursue support for patient-centered, life-affirming plans. These plans should meet the needs of subscribers at all stages of life.

Congress should also ensure that every health care plan has full transparency, so purchasers are aware of any controversial practices the plan covers. The ACA’s requirement that abortion premiums be paid separately—now enjoined by a federal court—should be enforced.

Conscience is a key element of a free and robust society in every sector, but especially health care. A decade on from enactment of the Affordable Care Act, the need for patient- and family-centered alternatives in health care is more acute than ever.


This article first appeared in The Daily Signal on December 18, 2020 and is reproduced with permission.


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Americans just witnessed the passage of the Inflation Reduction Act of 2022 without one Republican vote in the U.S. Senate and House (just as Obamacare was passed in 2010). The IRS  will be hiring 87,000 new agents, many armed, to terrorize American taxpayers.

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