TFAH Leadership Blog:

Advancing Public Health and Health Equity
March | 2024

The Affordable Health Care Act at 14: Preserve the Progress

This March marks the 14th anniversary of the enactment of the Affordable Care Act (ACA). Its passage was the most significant advancement of health policy since the establishment of Medicare and Medicaid in the 1960s and made healthcare accessible and affordable for millions more Americans.  Despite efforts to repeal and restrict the ACA, the progress the legislation has made toward health equity and improving public health prevention is significant and lifesaving. It must be preserved.

The ACA was signed into law in March 2010 during the 110th Congress. Some of the major provisions of the legislation include the creation of a public marketplace for health insurance, expansion of Medicaid eligibility to many adults with low incomes, coverage of recommended preventive services, and the establishment of the Prevention and Public Health Fund.

In the decade leading up to the ACA’s passage, the percentage of people without health insurance steadily increased, reaching over 16 percent of all U.S. residents in 2010, according to the U.S. Census Bureau. Preventive services such as mammograms and other cancer screenings, diabetes screenings, and vaccinations were a costly expense and not easily accessible for a significant number of Americans.

Health insurance enrollment has soared in the years since the Affordable Care Act became law. Forty states and D.C. have expanded Medicaid. As a result, many of those states saw a significant decrease in the share of people without insurance. Nationally, the percentage of uninsured adults between 18-65 steadily decreased to 12.2 percent in 2022, according to the Centers for Disease Control and Prevention. Uninsurance rates also dropped significantly for Black, Latino, and Asian Americans, and for households with lower-incomes.

Medicaid expansion has had significant benefits related to greater health insurance coverage. Mortality rates declined in states that expanded Medicaid eligibility to more adults with low incomes, according to a 2021 study (using data from before COVID-19 was declared a public health emergency). Expansion has contributed to healthcare affordability, access and utilization of care, financial security, and positive impacts on state economies.

Additionally, the ACA ensured access to vital preventive care and screenings without a copay. Prior to the ACA, many health plans failed to cover preventive services, and those that did often required individuals to pay a share of the costs. Even small out-of-pocket payments have been shown to deter people from accessing preventive services, particularly people with lower incomes.

The creation of the Prevention and Public Health Fund (PPHF) has been an important tool for improving health outcomes and reducing health expenditures. To date, PPHF has provided over $12 billion to states and territories to expand access to immunizations, strengthen detection of diseases, and prevent chronic diseases. One program supported by PPHF, the Tips from Former Smokers Campaign, has helped one million smokers quit for good, preventing an estimated 129,000 early deaths.

Yet, the ACA’s progress continues to be at risk.

Ten states have yet to expand Medicaid eligibility. And the current unwinding of continuous Medicaid enrollment that was authorized during the COVID-19 public health emergency has left many individuals and families without health coverage.

Litigation currently moving through the courts threatens access to preventive services. TFAH joined other public health organizations and scholars in an amicus brief describing the potential harms of overturning ACA’s preventive services coverage requirements. Should the courts overturn part or all of this important protection, millions of Americans could lose access to these life-saving services.

An additional threat to the ACA’s impact is the use of monies that should be directed to the Prevention and Public Health Fund to other legislation or priorities. To date, nearly $13 billion has been redirected in this manner. Most recently, the proposed costs in the Protecting Health Care for All Patients Act of 2023 were offset by taking more than $1 billion from PPHF. TFAH was joined by more than 100 organizations in a letter opposing these cuts.

TFAH will continue to urge Congress to restore funding for the Prevention and Public Health Fund and protect access to preventive services.

The ACA is a critical catalyst toward the goal of ensuring the opportunity for optimal health for everyone. It has unlocked access to healthcare including preventive services for so many in this country, including those at the highest risk of poor health. We can’t afford to turn back.