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10 Years Of The Affordable Care Act


This was the scene at the White House 10 years ago today.


PRESIDENT BARACK OBAMA: Today after almost a century of trying, today after over a year of debate, today after all the votes have been tallied, health insurance reform becomes law in the United States of America.

SHAPIRO: That was President Barack Obama signing the Affordable Care Act into law. Julie Rovner covered the law's passage and implementation for NPR back then, and she is now at our partner Kaiser Health News. She's with us to talk about how the ACA has changed health care in the past decade and also how the current coronavirus pandemic might change the Affordable Care Act.

Hi, Julie.

JULIE ROVNER: Hi, Ari. Thanks for having me.

SHAPIRO: So much of the Affordable Care Act is about access to health insurance. Is it making a difference in this coronavirus outbreak?

ROVNER: Well, it is, although not in the way you might think. The health law was mostly about health insurance. Around 20 million more people have insurance than had it before the law was passed, and that insurance means that doctors and hospitals and clinics have all gotten paid over the past several years that might not have otherwise if those people had remained uninsured. It's kept some hospitals open that otherwise would have closed. Meanwhile, other parts of the law shored up other parts of the health care system, particularly things like making preventive care more available and boosting the supply of health professionals. So I think it's safe to say that while the health system is not ready to weather the coming storm if things get really, really bad, it would have been so much worse if not for the Affordable Care Act.

SHAPIRO: Remind us what the health care system looked like before this law passed. What were the biggest problems?

ROVNER: Well, there were two big problems. Health care costs too much, which it still does, although for other reasons. And too many people didn't have - and many of them couldn't get - health insurance. For example, back in 2008, I spoke to Barb Fleming. She's a self-employed saleswoman from Missouri with individual insurance who was diagnosed with breast cancer. Her insurer wouldn't renew her policy because it didn't have to. And while she was able to get into her state's high-risk pool, that coverage wasn't very helpful.


BARB FLEMING: I was approved for the pool as of March 4, which is the day I needed insurance, but it would not cover my cancer. So I was going to be paying $908 a month for an insurance - and I have been - that was not covering the cancer.


ROVNER: So the Affordable Care Act did solve that problem by requiring that insurance cover pre-existing conditions. It also did other things to boost coverage, like outlawing lifetime dollar limits on medical care and letting parents keep adult children on their health plans until they reach age 26.

SHAPIRO: So by late 2009, the first year of the Obama presidency, Democrats had a large majority in the house. They had 60 votes in the Senate. Those numbers suggest that it might have been easy for them to pass this law, but it wasn't. Why not?

ROVNER: Well, Democrats, as well as Republicans, have long had internal splits over what to do about health care. And while a lot of the groundwork was laid for this law even before President Obama was elected, Democrats still argued over big issues like whether to include a public health plan people could sign up for. That's the so-called public option. And the issue that almost derailed the bill several times - abortion. The goal of the sponsors was to make the law what they called abortion-neutral - so to neither expand or contract abortion rights. But actually writing that goal into the legislation turned out to be incredibly difficult.

SHAPIRO: OK. So the law passes, and President Obama signs it on March 23, 2010. And it seems like since then, it has been having constant near-death experiences.

ROVNER: Yes, that is absolutely true. The law has been on the edge of elimination several times. The first big threat was a lawsuit challenging the constitutionality of the requirement for most Americans to either have insurance or pay a fine, the so-called individual mandate, that went to the Supreme Court in 2012. And to the surprise of many, it was upheld with the pivotal vote of Chief Justice John Roberts. Here was President Obama on that June day.


OBAMA: The highest court in the land has now spoken. We will continue to implement this law, and we'll work together to improve on it where we can. But what we won't do, what the country can't afford to do, is refight the political battles of two years ago.

ROVNER: Well, of course, that's not what happened.


ROVNER: Most Republican governors refused to cooperate in their states. They didn't set up their own insurance marketplaces. They wouldn't do any marketing so people could know that insurance was available and affordable. They could get subsidies if they signed up. But most critically, at least in the first years, most of them didn't expand the Medicaid program for people with low incomes, which the Supreme Court ruling had made optional. So even right now in some really big states like Texas and Florida, there are millions of people who were supposed to be able to get Medicaid coverage under the law but instead are still uninsured.

SHAPIRO: So in 2016, Donald Trump runs for president, and he promises to get rid of the Affordable Care Act.


PRESIDENT DONALD TRUMP: Obamacare has to be repealed and replaced, and it has to be replaced with something much less expensive for the people. And otherwise, this country is in even bigger trouble than anybody thought.

SHAPIRO: It was not repealed and replaced, but the Trump administration did weaken the law. So how strong is the Affordable Care Act today?

ROVNER: Well, it has weathered an awful lot of storms. And there's yet another lawsuit that the Supreme Court will hear in the next term that could again get the entire law struck down. It was brought by a group of Republican state attorneys general. Ironically, the Trump administration is supporting that lawsuit even as the Affordable Care Act is being used right now to lessen the impact of the coronavirus crisis.

SHAPIRO: OK, so let's talk a little bit more about the relationship between the ACA and coronavirus. I mean, you've mentioned that millions more people have health insurance now than otherwise would. How else is the ACA being used to fight this outbreak?

ROVNER: Well, at least nine states have reopened their Affordable Care Act marketplaces to help enroll people who didn't sign up for insurance and now think they might want it. I should point out that if you lose your job and your health insurance, you're automatically entitled to sign up for coverage mid-year under the law. Meanwhile, California announced Friday that its exchange, which had been open for reasons unrelated to the outbreak, will continue to allow residents to enroll through June because of the upheaval caused by the coronavirus. The Trump administration could choose to reopen enrollment nationwide if it wanted to, and there are reports it's considering doing just that.

SHAPIRO: You know, the health system is under such duress right now. What does the future of the Affordable Care Act look like in light of what the health system is going through with the coronavirus outbreak?

ROVNER: Well, as I mentioned earlier, despite its name, the Affordable Care Act did a lot more to fix problems with insurance coverage than it did to actually make health care affordable. Ten years later, people are still complaining about premiums and co-pays and surprise medical bills. People still declare bankruptcy because of medical bills. And most significantly for this crisis, many people with insurance say they still avoid seeking medical care because they worry about what it might cost. And public health experts say that's a big problem and one you're not seeing in most of the other countries dealing with the crisis at the same time. What you don't want is Americans with coronavirus not getting tested or seeking care if they should and then spreading the virus to others.

I think there are also going to be long-term political ramifications to this crisis. I'm already hearing the I-told-you-sos from advocates for a single-payer system, the "Medicare for All" proponents. People are asking why we can't have faster and better testing like South Korea, and one reason is that they have a single, streamlined national health system compared to our fragmented non-system. So I think when this is all over, Americans and public officials are going to have a very different attitude about our health care system and what it should do and who should pay for it. And I think it really could change the debate very profoundly.

SHAPIRO: That is Julie Rovner, a familiar voice to NPR listeners. She is now chief Washington correspondent at Kaiser Health News.

It's great to talk to you again, Julie. Thanks.

ROVNER: Thank you.

(SOUNDBITE OF ARVO TO ME'S "MND WRKS") Transcript provided by NPR, Copyright NPR.