The Affordable Care Act, also commonly referred to as the ACA or Obamacare, was signed into law by President Barack Obama on March 23, 2010. Obama had assured the public during his presidential campaign that healthcare reform would be one of his top priorities if he were elected president. Fixing healthcare became a key promise of candidate Obama and Democrats running for Congress in 2008, and a key agenda item of the Obama administration and the 111th U.S. Congress.
This strategic focus on healthcare was in large part due to the increasingly alarming number of Americans not having medical insurance along with medical expenses being the leading cause of bankruptcy in the United States. Specifically, it was estimated that approximately 45 million people were lacking health insurance and over 1.5 million people annually were filing for bankruptcy due to burdening medical expenses. While Democrats won large majorities in both the House of Representatives and the Senate in the 2008 elections, passing the ACA through both chambers of Congress was cumbersome and difficult, as it encountered not only Republican opposition but also a coordinated conservative media campaign.
In July 2009, House Speaker Nancy Pelosi announced the plan for overhauling the healthcare system, and in March 2010 President Barack Obama signed the bill into law. In this time frame, the ACA passed in the House of Representatives in November 2009, with 219 Democrat votes and only one Republican vote in favor and with 39 Democrat votes and 176 Republicans votes against it. The ACA also passed in the Senate in December 2009, with 58 Democrats and 2 independents voting in favor but with 39 Republicans voting against it and one Republican being absent. However, in January 2010 Republican Scott Brown won the Massachusetts Senate seat previously held by the late Democratic Senator Ted Kennedy. Democrats no longer had a filibuster proof Senate majority, so they used the budget reconciliation process, which did not require 60 Senators but rather only 51, to enable the President to sign the ACA into law. Finally, a bill reconciling the House of Representatives and the Senate versions of the ACA passed in both chambers of Congress in March 2010. In the course of this tedious effort to pass the new healthcare bill, Democrats in Congress had to drop specific progressive agenda items such as a public health insurance option.
The main goal of the Affordable Care Act was to reform the healthcare system in order to make it accessible and affordable for more Americans. For example, the ACA has several major provisions aimed at increasing the availability and decreasing the cost of health care, including no longer allowing healthcare providers to deny coverage based on preexisting conditions such as chronic diseases, allowing children to remain on their parents’ health insurance until the age of 26, and ensuring that essential health benefits such as emergency care and substance use disorder services are provided. To reduce the substantial costs commonly associated with healthcare coverage, the ACA has expanded Medicaid eligibility, has offered lower income families savings on health insurance plans through premium tax credits and cost sharing reductions, and has established a federal health insurance marketplace while also encouraging the creation of state health insurance exchanges. Additionally, to provide flexibility, the ACA includes four tiers of coverage – bronze, silver, gold, and platinum – which carry varying out-of-pocket costs and deductibles. ACA provisions have also included mandates. An employer mandate has established that employers must offer health insurance that is affordable and provides minimum value to 95% of full-time employees and their children under 26, or be subject to penalties. An individual mandate has established that most U.S. citizens and legal residents are required to have health insurance, or pay a non-compliance penalty. These reforms have had positive impacts such as increasing the accountability of the healthcare industry and reducing the number of uninsured Americans by approximately half. However, following the rollout of the ACA, the mandates became unpopular, particularly among people identifying politically as Republicans.
Since 2010, there have been over 60 attempts by Republicans in Congress to repeal all or at least parts of the Affordable Care Act. However, to date, such attempts have largely failed except in regards to defunding specific aspects of its implementation. In 2011, after Republicans gained control of the House of Representatives, one of their first bills was the “Repealing the Job-Killing Health Care Law Act,” which passed 245 to 189, but was then defeated in the Senate, which had remained under the control of Democrats. In October 2013, Republicans in the House of Representatives refused to pass a bill to fund the federal government unless it was accompanied by either a repeal or at least a delay in implementation of the ACA, sparking a deadlock that resulted in a government shutdown. In 2015, after Republicans also gained control of the Senate, Congress passed the “Restoring Americans’ Healthcare Freedom Reconciliation Act” that was vetoed by President Obama and then failed to receive a supermajority in Congress to override the veto. In 2017, despite Republicans holding the presidency as well as majorities in both chambers of the Congress, Senator John McCain dramatically tanked a Republican effort for even what became known as a “skinny repeal” of the ACA.
Republicans have also sought to challenge the legality of the ACA in the judicial system. In 2012, in National Federation of Independent Business v. Sebelius, the Supreme Court narrowly refused to deem the individual mandate as unconstitutional by reinterpreting it as a tax. On November, 10, 2020, the Supreme Court heard oral arguments in California v. Texas, a lawsuit filed by a coalition of Republican state attorneys general and the Trump administration to again challenge the individual mandate of the ACA after the 2017 Tax Reform Act had removed its monetary penalty. After the passing of Justice Ruth Bader Ginsburg and the recent confirmation of Justice Amy Coney Barrett, the Supreme Court currently has a 6-3 conservative majority, which has concerned some legal experts. Nevertheless, a conservative majority on the Court does not necessarily mean that Court decisions will always support conservative policies, as Justices pledge to make decisions based on the constitutionality of a law and not their own political beliefs. During the oral arguments in California v. Texas, Chief Justice John Roberts and Justice Brett Kavanaugh, who often vote along conservative lines, signaled hesitation in striking down the entirety of the Affordable Care Act. Although there may be five votes to deny the constitutionality of the individual mandate of the ACA and thus to stop directing people to buy health insurance, a majority of the Court seems to agree that the rest of the ACA can survive. Justice Kavanaugh suggested that, under court precedent, cutting out the individual mandate while leaving the rest of the bill intact was “straightforward.” Justice Roberts even more clearly stated that, since Congress did not terminate the ACA but only weakened one of its mandates, it appeared that “they wanted the Court to do that but that’s not our job.”
The news that the Supreme Court might not strike down the entirety of Obamacare has been viewed differently by different constituencies divided almost strictly along party lines. While over 50 percent of the U.S. population currently supports the ACA, nearly 80 percent of Democrats appreciate this law and approximately 80 percent of Republicans oppose it.
If the Supreme Court were to overturn the Affordable Care Act, tens of millions of Americans would immediately lose access to healthcare coverage or would at least be denied coverage, which would adversely impact those who rely on the law for healthcare coverage and benefits. The stakes are particularly high considering the pandemic. Young adults over the age of 18 but under the age of 26 would no longer be included on their parents’ health insurance plans and as such would be among those most at risk of losing healthcare coverage. Private healthcare providers would be allowed again to take actions that the ACA had terminated, such as denying coverage based on preexisting conditions or charging higher premiums due to preexisting conditions, placing limits and caps on health care for individuals with chronic conditions or severe diseases, and refusing to cover preventative medicine practices such as screenings. Health insurance companies would also no longer be required to spend at least 80 percent of premiums on medical care and improvements and could return to practices of using large portions of their profits for campaigns and activities to limit or deny coverage. It has also been projected that striking down the ACA would result in increases in costs of prescription drugs.
However, many Republicans continue to attack the ACA. Conservative groups argue that the ACA has brought higher health insurance monthly premiums and higher annual taxes. Such groups also claim that the individual mandate has been detrimental to people being fined for not purchasing health insurance, whereas the employer mandate has been detrimental to businesses having to either cut employee hours or limit development in order to meet the requirement for health care coverage for employees working at least 30 hours per week and their families. In the aftermath of the oral arguments in California v. Texas and in particular based on the comments made by several Justices, it seems that many Republicans’ hope that the entirety of the ACA would be ruled unconstitutional by the Supreme Court will again not be realized. It is likely that even if the individual mandate might no longer be allowed, the majority of the Supreme Court Justices believe that the individual mandate can be safely severed from the rest of the ACA without compromising the whole law. However, regardless of what the Supreme Court decides in California v. Texas, the ACA’s future still remains uncertain, as attacks from Republican lawmakers will likely continue in the hope of repealing all or large parts of the ACA in the future, which would most likely happen if Republicans were to regain control of the presidency and both chambers of Congress in future election cycles.