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A Review of the Affordable Care Act at 10 Years

Two weeks ago marked the tenth anniversary of the enactment of the Affordable Care Act (ACA).  Given the ongoing COVID-19 pandemic,  it is understandable why the anniversary has largely flown under the radar.  However, now is as good a time as any to reflect on all the controversy that has surrounded the law over the last decade, as well as how much the law has accomplished. While far from comprehensive, our upcoming blog series will review some of the impacts the law has had on the U.S. healthcare system, in particular focusing on the legal issues and debates that have surrounded the law.  Mintz has previously covered many of these items, and links to our prior coverage is included throughout.[1] 

Around noon on March 23, 2010, as he finished signing the ACA into law in the East Room of the White House, then-President Barack Obama concluded the ceremony by remarking: “We are done.”[2]  He was specifically joking about the literal amount of time he had just spent physically executing his signature on the bill because of the number of pens he had to use, though one also could have easily interpreted that statement to have dual meaning.  At the time, enactment of ACA appeared to be the end of not just the contentious legislative process that preceded its passage, but also the completion (on some level) of the Democratic Party’s long-standing objective of passing significant health care reform legislation.  

There were several signs even in March 2010 that the ACA would be subject to years of legislative and judicial disputes.  Among other reasons, the legislation was enacted with no Republican votes and with the Senate employing the budget reconciliation process, thereby requiring only a simple majority for enactment.[3]  Additionally, as the President made his remarks, Florida was concurrently filing a lawsuit in federal district court challenging the constitutionality of two major provisions of the law: the individual mandate and the Medicaid expansion.  That case, which was later joined by 25 other states and private plaintiffs including the National Federation of Independent Businesses (NFIB), would become the first significant legal challenge to the ACA.  In the last decade, the ACA has been the subject of myriad court battles, a handful of which have reached the Supreme Court.  There have also been significant legislative attempts to repeal either portions or the entirety of the law, one of which is currently pending in the Supreme Court.

As a result of some of these high-profile cases, many other, unchallenged provisions of the law have received less attention.  The impact of such provisions are nevertheless important. Despite the simplicity of the ACA’s goals – to increase access to health insurance for uninsured individuals and lower the cost of coverage for those already insured – the ways in which the law sought to accomplish these aims were wildly complex and interconnected and have resulted in fundamental changes to several aspects of the U.S. healthcare system. This complexity is reflected in the major components of the law, which we will examine throughout this blog series, including:

  • An “individual mandate” requiring most individuals to obtain health coverage or pay a penalty, along with an “employer mandate” requiring most employers with 50 or greater full-time equivalent employees to provide qualifying health coverage;

     

  • Requiring states to expand Medicaid eligibility to low-income adults;

     

  • Requiring health plans to comply with federal standards for health coverage;

     

  • Establishing health insurance exchanges where individuals and small employers could purchase qualifying health coverage, along with means-tested subsidies to help individuals pay for the premiums and subsidies for these marketplace plans, and premium stabilization programs to mitigate market failures; and

     

  • Implementing various programs to test alternative payment models.[4]

     

Notwithstanding the law’s various interlocking components, the ACA as a whole has had a substantial impact in reducing the number of uninsured Americans.  There is a growing body of evidence showing improvements in access to care and lowering of the health care cost inflation curve as a result of the ACA.  Between passage of the law in 2010 and 2017, the number of uninsured in the U.S. dropped from 44.2 million to 27.4 million (17.8% and 10.2% of the population, respectively).[5]  While the uninsured rate in 2010 was arguably inflated due to the number of people who became unemployed as a result of the financial crisis, it is notable that the steepest decline in uninsured individuals coincided with the implementation of major provisions of the law.  As a result, more than 20 million people gained coverage during this period.[6] 

Early studies on the law also provide evidence of improvements in access to care, quality of care, and health outcomes for non-elderly adults.  A recent Commonwealth Fund survey found that between 2010 and 2018, the share of non-elderly adults who reported having a problem paying a medical bill fell by 17%, the percentage who did not visit a provider when needing care fell by 19%, and the share who skipped a test or treatment fell by 24%.[7]  There is also evidence that the ACA has led to improvements in certain economic measures and a reduction in overall health care spending.[8]  In 2019, CMS released updated projections of national health expenditures and found that between 2010 and 2019, actual spending was significantly lower than pre-ACA projections, with spending in Medicaid, Medicare, and by private insurers dropping 21.5%, 18.2%, and 6.1%, respectively, from CMS’s pre-ACA projection.[9]


[1] For example, this blog series will not touch on some high-profile components of the law, such as the action surrounding the Cadillac Tax, or the Supreme Court case Burwell v. Hobby Lobby, both of which Mintz has written about on the blog. Please refer to our posts on these subjects for more information.

[2] Gov’t Printing Office, Administration of Barack H. Obama, 2010 Remarks on Signing the Patient Protection and Affordable Care Act March 23, 2010: https://www.govinfo.gov/content/pkg/DCPD-201000196/pdf/DCPD-201000196.pdf.

[3] The enactment was further complicated by the unexpected victory by then-Senator Scott Brown to the late Senator Ted Kennedy’s seat via a special election, which occurred after the Senate passed its version of the bill, but before the final Senate and House bills could be reconciled in joint committee and the final text could be passed by both chambers.  To avoid having the Senate vote once more on the final bill, the House adopted the full text of the Senate’s bill, which no one had expected to be the final draft of actual legislation signed into law. The House then had to rely on the Senate to pass a “corrections bill” to address any changes the House wanted to the final legislation.  The Senate used a parliamentary tactic called budget reconciliation to pass the corrections bill, but the corrections bill included several errors, including its failure to necessary appropriations language for several programs. See John F. Cogan, "The High Cost of Good Intentions: A History of U.S. Federal Entitlement Programs" (2017).  

[1] For example, this blog series will not touch on some high-profile components of the law, such as the action surrounding the Cadillac Tax, or the Supreme Court case Burwell v. Hobby Lobby, both of which Mintz has written about on the blog. Please refer to our posts on these subjects for more information.

[2] Gov’t Printing Office, Administration of Barack H. Obama, 2010 Remarks on Signing the Patient Protection and Affordable Care Act March 23, 2010: https://www.govinfo.gov/content/pkg/DCPD-201000196/pdf/DCPD-201000196.pdf.

[3] The enactment was further complicated by the unexpected victory by then-Senator Scott Brown to the late Senator Ted Kennedy’s seat via a special election, which occurred after the Senate passed its version of the bill, but before the final Senate and House bills could be reconciled in joint committee and the final text could be passed by both chambers.  To avoid having the Senate vote once more on the final bill, the House adopted the full text of the Senate’s bill, which no one had expected to be the final draft of actual legislation signed into law. The House then had to rely on the Senate to pass a “corrections bill” to address any changes the House wanted to the final legislation.  The Senate used a parliamentary tactic called budget reconciliation to pass the corrections bill, but the corrections bill included several errors, including its failure to necessary appropriations language for several programs. See John F. Cogan, "The High Cost of Good Intentions: A History of U.S. Federal Entitlement Programs" (2017).  

[4] C. Stephen Redhead and J. Kinzer, Legislative Actions in the 112th, 113th, and 114th Congresses to Repeal, Defund, or Delay the Affordable Care Act (February 7, 2017).

[5] Kaiser Family Foundation analysis of the 2017 American Community Survey (ACS), 1-Year Estimates.

[6] Id

[7] S. Collins, H. Bhupal, and Michelle Doty, The Commonwealth Fund, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured (Feb. 2019),

[8] Additionally, there is a growing body of evidence showing improvements in economic measures as a result of the ACA, including changes to payor mix and other impacts on hospitals and providers, improvements in state budgets and economies, Medicaid spending per enrollee, and positive improvements in employment and labor markets. M. Guth, R. Garfield, and Robin Rudowitz, Kaiser Family Foundation, The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review (Mar. 17, 2020). For example, two recent studies examining some of the secondary effects of the Medicaid expansion have also found decreases in the prevalence of severe food security and large reductions in the coverage gap in states that expanded, respectively. Gracie Himmelstein, “Effect of the Affordable Care Act’s Medicaid Expansions on Food Security, 2010–2016”, American Journal of Public Health 109, no. 9 (September 1, 2019): pp. 1243-1248.

[9] Paul N. Van de Water, Ctr on Budget and Pol’y Priorities, More Evidence of Post-ACA Slowdown in Health Care Spending.

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Xavier Hardy Health Care Lawyer Mintz
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Xavier focuses his practice on a variety of health care regulatory and fraud and abuse matters as well as Medicare and Medicaid reimbursement issues in health care transactions and business arrangements. He represents clients in the health care and life sciences industries.

Prior to joining Mintz, Xavier was an associate in the Washington, DC office of a national law firm. In that role, he advised clients on legal and regulatory issues around health care reimbursements involving Medicare, Medicaid, and other third-party payors. He also counseled...

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Thomas Crane, Health Care Attorney, Mintz Levin, Anti-Kickback Lawyer, FLSA,Health Care Compliance, Fraud & Abuse, and Regulatory Counseling Medicare, Medicaid & Commercial Coverage & Reimbursement Health Care Enforcement & Investigations White Collar Defense & Government Investigations
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Tom is nationally recognized for his work defending health care clients against anti-kickback, Stark Law, false claims, and whistleblower allegations. His work includes litigation, internal investigations, corporate integrity agreements, and self-disclosures. Tom also counsels clients on the legal, practical, and fraud and abuse implications of business arrangements and sales and marketing practices. Additionally, Tom has worked with several academic medical center clients in restructuring arrangements among medical school, teaching hospital, and faculty physicians. Tom gained national recognition for his work on the anti-kickback statute during his tenure at the HHS Office of Inspector General, where he prosecuted the Hanlester Network case and was the principal author of the 1991 safe harbor regulations. He is an elected Fellow of the American Health Lawyers Association.

Tom is nationally recognized for his experience with fraud and abuse. Practicing in Boston and Washington, DC, he advises national and local clients on structuring complex strategic affiliation arrangements and transactions to comply with the applicable fraud and abuse laws as well as the variety of other regulatory requirements to meet today’s health reform challenges. His work in defending clients against anti-kickback, Stark Law, false claims, and whistleblower allegations includes litigation, internal investigations, self-disclosures, and negotiating settlements and Corporate Integrity Agreements (CIAs).

He has appeared before numerous US attorneys’ offices, the FBI, and the Office of Inspector General (OIG) and Centers for Medicare & Medicaid Services (CMS) around the country and in Washington. In addition, he has served as an expert witness and consulting expert in health care fraud cases.

In addition to his fraud and abuse defense work, Tom advises clients on the legal, practical, and fraud and abuse implications of business arrangements and sales and marketing practices. This part of his practice focuses on Medicare and Medicaid fraud and abuse compliance and reimbursement issues and related laws, including the federal Physician Payments Sunshine Act, ‘meaningful use’ of EHR technology, under arrangement and provider-based rules, and OIG issues.

Tom has implemented and audited comprehensive corporate compliance programs for clients in various health care sectors.

His clients have included hospital systems and executives, medical device and pharmaceutical manufacturers, pharmacies and pharmacy benefit management companies, physicians and groups, renal dialysis providers, supply companies, home care providers as well as national and state trade groups.

He became nationally known for his work on the anti-kickback statute during his tenure at the Office of Inspector General at the Department of Health and Human Services in Washington, DC. In particular, Tom gained recognition as a prosecutor in the Hanlester Network joint venture case and as the principal author of the 1991 safe harbor regulations.

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