Reviewing How the Affordable Care Act Improved the Health Coverage Landscape

The Affordable Care Act (ACA) gave millions of newly eligible people access to affordable, comprehensive health insurance. Undoing the ACA’s coverage expansions or undermining its consumer protections — let alone repealing the law — threatens to bring back serious challenges people used to face in accessing coverage.

Here’s a roundup of analyses showing how the ACA changed the health coverage landscape. It increased health coverage rates, established new protections for people with pre-existing conditions, made health benefits more affordable and comprehensive, and improved health and financial security for millions of people.

Before the ACA:

Tens of millions more people lacked coverage, and uninsured rates were nearly double current levels.

• Entering Their Second Decade, Affordable Care Act Coverage Expansions Have Helped Millions, Provide the Basis for Further Progress
  • The ACA expanded health coverage options for millions of people by creating insurance marketplaces with financial assistance for premiums, deductibles, and other costs, and by allowing states to expand Medicaid to cover adults with incomes up to 138 percent of the federal poverty level ($20,783 for an individual in 2024).
  • Since the ACA’s major coverage provisions were implemented, the uninsured rate has fallen by nearly half, from 14.5 percent (45.2 million people) in 2013 to just 8 percent (26.4 million people) in 2022.
• The ACA’s coverage expansions in Medicaid and in the individual health insurance market contributed to widespread declines in uninsured rates across states. People of color are among the multiple groups seeing these declines. Hover over a state below for details:

• Groups also benefiting:
  • people with low incomes;
  • people who are LGBTQ+;
  • people with pre-existing conditions; and
  • people with limited access to employer-sponsored coverage.
• Record Low Uninsured Rate Offers Roadmap to Long-Term Coverage Gains
  • In recent years, the ACA has continued to improve access to coverage through the marketplace via improved premium tax credits, expanded enrollment periods, and increased outreach and enrollment assistance, including record funding for its Navigator program.

The individual market, where people buy coverage on their own, was dysfunctional and unaffordable, leaving millions of people with no access to coverage for their health conditions, limited or missing benefits, and high out-of-pocket costs. Employer coverage had fewer protections.

• Eliminating Federal Protections for People with Health Conditions Would Mean Return to Dysfunctional Pre-ACA Individual Market
  • The ACA established important consumer protections like out-of-pocket cost limits, cost-sharing standards, and bans on annual or lifetime coverage limits. It also streamlined the enrollment process by creating a federal marketplace and requiring comprehensive benefits across plans.
  • Before the ACA, insurers could charge higher premiums for, or deny coverage to, people with "pre-existing" conditions like diabetes, asthma, or pregnancy — practices that limited access to health care and led to higher out-of-pocket costs and uninsured rates. The ACA prohibited coverage denials and premium increases for people with these conditions.
• If “Essential Health Benefits” Standards Are Repealed, Health Plans Would Cover Little
  • Under the ACA, all individual and small-group health plans are required to cover ten essential health benefits: emergency services; hospitalizations; outpatient care; maternity and newborn care; mental health and substance use disorder treatment; prescription drugs; rehabilitation services; laboratory services; preventive services and chronic disease management; and pediatric care.
  • Prior to the ACA, many people in the individual market (62 percent) had plans that didn’t cover maternity care, substance use disorder treatment (34 percent), mental health care (18 percent), or prescription drugs (9 percent) — meaning those services had exorbitant costs.
• Health Care: Issues Impacting Cost and Coverage
  • The ACA made several improvements to health plans across all markets, including employer coverage. It prohibited lifetime and annual benefit limits, required plans to cap out-of-pocket costs, and required that young adults be allowed to remain on their parents’ plans until age 26.

Limited Medicaid eligibility and costly insurance options left people with less access to care, widespread financial insecurity, and poorer health outcomes. Also, inequities across racial and ethnic groups were greater.

• Medicaid Expansion: Frequently Asked Questions
  • The ACA’s Medicaid expansion improved chronic disease management and lowered rates of maternal and infant mortality and premature death.
  • Medicaid expansion also protects enrollees from catastrophic out-of-pocket medical costs, improving overall financial security. Under expansion, fewer adults struggle to pay medical bills or face medical debt, bankruptcies, and evictions.
• Health Coverage Rates Vary Widely Across — and Within — Racial and Ethnic Groups
  • Following the ACA’s implementation, health coverage inequities narrowed between racial and ethnic groups.