The Affordable Care Act at 15 Years Old: An Honest Appraisal

One thing that has become very clear to me in the course of my 64 years is that many huge and important things have positive and negative sides.

Wisdom comes from honestly appraising both sides of any issue or performance. Getting mad is not generally useful. But too much contentment can be a bit of a trap as well. If your evaluation is honest, you will always irritate one side or the other. But you can’t be afraid of it; fear serves no one.

Today, I’m appraising the 15-year performance of the Patient Protection and Affordable Care Act (ACA). The original Senate bill, coupled with the House of Representatives’ version (the Healthcare Education and Reconciliation Act), has reshaped the authority, delivery and financing of healthcare dramatically since signed into law in 2010. You can read all about the origins of the bill here.

I realize there are strong political feelings about the ACA. But for this post, I’m giving you a fact-based, honest appraisal of how it’s changed healthcare and how those changes have manifested.

The Good …

From the perspective of a patient in a healthcare setting, the ACA has achieved clear societal good. For example:

• Around 40 million people today have healthcare coverage that is directly financed via mechanisms created by the ACA.
  • The ACA created a 90% federal matching rate for a new Medicaid eligibility group (coupled with provider taxes to generate more state-level funds). The new category for able-bodied adults with incomes between 100-138% of the Federal Poverty Level added millions of people to health insurance coverage via Medicaid. To date, 41 states plus the District of Columbia have adopted this change.
  • The ACA created nationwide marketplaces, heavily subsidized by Advanced Premium (federal) Tax Credits, which has enabled more than 20 million people to hold individual health insurance coverage as of fall 2025.
  • Clear national standards for individual and small group (size 2 to 50 employees) health insurance nationwide have simplified these markets and added guaranteed issue This means health insurance membership AND rates are not predicated on health status.
  • These changes collectively have removed worry from health insurance premiums for millions of Americans.

The Worrisome …

• The achievements in the “good” category have required massive changes in spending, regulations, authority, costs, insurance markets and availability of medical providers. Some of these changes are negative.
  • Consolidating the regulatory power of health insurance in Washington, D.C., via federal agencies (like the departments of Health and Human Services, Labor and Treasury) has made these programs fodder for congressional debates almost every single year. Some of these debates have led to government shutdowns. This did not happen when authority over health insurance rested with the states.
  • The robust insurance coverage requirements in the ACA mean that healthcare costs have skyrocketed since passage. Since typically 85% of health insurance premiums are spent on nothing but healthcare, this means the cost of the insurance program has skyrocketed as well. To insulate insured members from these increases, Advanced Premium Tax Credit spending is roughly triple the original projections per person per year.
  • Lax enforcement of rules around the breadth of provider networks within health plans means that enrollees often find themselves with coverage but no doctors available for them to see. Fortunately, here at Louisiana Blue, we have not allowed this to happen.
  • Severe profit limitations via the MLR rules passed in the ACA have led large, well-funded health insurance companies to seek vertical integration within healthcare to buoy their earnings. This integration is driving up costs at rates well above inflation.
  • Employers are continuing to provide insurance in this environment, despite massive cost increases since 2010 and more regulatory hurdles to overcome just to keep a benefit plan in place. But, as employer coverage has increased in price, employers are less willing to fund coverage for families, dependents and spouses. This means more of the burden of covering an employee’s family is falling to the employees themselves. We are noticing that fewer families are buying coverage through the wage-earner’s employer than 10 years ago.
  • The ACA does virtually nothing to help control the distribution, coverage or increasingly unaffordable costs of prescription drug plans for employers or carriers. States have tried capping copays to help individuals, which is driving up costs even faster.
  • The authors of the ACA decided to use the insurance model of health insurance as a long-term solution, and succeeding administrations have systematically violated every successful tenet of that model, leading to instability and massive cost overruns.
    • The ACA as passed was projected to cost about $1 trillion over the first 10 years and raise almost that much in revenue via fines and Medicare changes. The expectation was, as passed, revenue neutrality and $0 new net costs to the federal budget.
    • The actual results (via Congressional Budget Office data) after all the post-passage changes to the ACA and enhancement of state reimbursements and advanced tax credits are currently estimated to be $1.5 trillion in cost overruns from 2015 to 2024.

As you can see, there are pros and cons associated with the ACA over its first decade and a half. Certainly, affordable health coverage is critical to the average American. Also certain is that the federal government’s ability to sustain the current financing model is under severe strain. Increasingly, ACA-based issues are causing more and more division in Washington, D.C.

The Straight Talk is, the ACA, the issue of healthcare and the amount of money involved are going to combine, continuing to spawn heated debate among voters for a long time. And I will continue to remember, monitor, follow and educate all my friends and neighbors on what is happening to their health insurance and why. These are critical issues I am obligated to keep you up to date on. Nothing less will do.