By Sean Miskell

Since the Affordable Care Act (ACA) became law five years ago today, health reform has unfolded in fits and starts amid political opposition and staggered implementation of its insurance market reforms and coverage expansions. But as a result of these occasionally frantic first years of implementation, children and families now have improved access to health coverage that is more stable and secure. To account for all the changes that the ACA has ushered in, it is helpful to consider the health policy landscape on March 22, 2010.

• Less access to Medicaid for millions of low-income Americans. Because states and the federal government jointly administer Medicaid, states have flexibility to determine who is eligible for coverage under the program. The ACA called for all states to expand access to Medicaid by raising the eligibility level to 133 percent of the federal poverty level (FPL). Though the Supreme Court eventually made doing so an option for states, to date 28 states have expanded Medicaid. As a result, 2 million more have coverage. If all states had taken up the ACA Medicaid expansion, millions more would have coverage as well. In addition to covering more people, expanded Medicaid is good for state budgets and public health. Just this weekend, the American Diabetes Association released a study finding that states that have expanded Medicaid have been much more successful in identifying patients with diabetes compared with states that have not. In the first half of 2014, the number of newly diagnosed Medicaid beneficiaries with diabetes rose by 23 percent in expansion states compared with less than half of one percent in non-expansion states. Expanding access to coverage helps patients identify their health issues and seek the care they need. 

• Millions locked out of coverage. Prior to the ACA, people with health conditions – those that need care the most – could be turned away by insurance companies. Many others may have been unable to afford insurance. But the ACA enacted a number of insurance market reforms that improved access to coverage. In addition to expanding access, the ACA established marketplaces where consumers could shop for health plans and qualify for subsidies to make this coverage more affordable. Since the state and federal insurance marketplaces first opened for consumers in 2014, 11.7 million people have been able to purchase health coverage. In the 37 states using the federal marketplace, 87 percent received financial assistance to help pay for their insurance. 

• An uncertain future for CHIP. Despite CHIP’s bipartisan popularity and proven record of success, it often faces an uncertain future and we cannot always assume that lawmakers will extend the program, or do so on time. (For example, CHIP funding extensions were vetoed twice in 2007). The ACA extended CHIP funding through 2015, and also extended or strengthened federal protections that help ensure stable coverage for kids, such as the ACA’s Maintenance of Effort provision that requires states to maintain their eligibility levels through 2019. 

The ACA’s reforms and coverage programs have had a profound effect in the past five years, as the uninsured rate has declined to 13.2 percent, down from 20.3 percent. But there is much work still to do. For these achievements to remain durable, they need to be defended and strengthened. In addition to the legal and political threats to the ACA’s reforms, there are many opportunities to build upon the ACA to expand access and improve health coverage. For example, on Say Ahhh!, we have discussed how millions more could have health coverage if more states expanded Medicaid and we have highlighted the need to improve the coverage available to children through the state and federal insurance marketplaces. And as we have seen, proven programs like CHIP face potentially harmful changes each time they come up for extension. But considering the pre-ACA landscape, it’s important to keep moving forward and build on the foundation of the ACA to ensure that all children and families have consistent access to affordable coverage.