The Affordable Care Act has been the law of the land for close to a decade, and yet it can seem that we've barely settled into it.
Headline after headline warns its existence is in jeopardy. Many states refuse to implement its core parts. President Donald Trump has wished for it to explode. A central provision has been declared unconstitutional.
Former President Barack Obama signed the Patient Protection and Affordable Care Act into law on March 23, 2010, saying the legislation codified the idea in the U.S. that "everybody should have some basic security when it comes to their health care."
What happened next, of course, didn't go as planned.
Recently, a federal court decided the central provision of the Affordable Care Act requiring all Americans to be insured or face a tax penalty is unconstitutional. Now, the entire law may be in limbo. Congress just repealed three taxes meant to raise revenue for the ACA.
In 2012, the Supreme Court ruled that Congress had exceeded its constitutional power by requiring states to expand Medicaid — one of the main ways the law aimed to increase coverage rates. At least 14 states have refused to expand their Medicaid program since.
"Changes to the ACA have come from many different quarters, including Congress, the administration, state governments and the federal judiciary system," said Christine Eibner, a senior economist at the RAND Corporation, a nonprofit think tank. "Many of these changes have reduced the law's reach in terms of expanding coverage."
Indeed, some 28 million Americans are still uninsured.
Even so, the Affordable Care Act has made our health-care system unrecognizable from a decade ago.
"I'd say, in many ways, the goals have been closer to met than not," said Gregory Stevens, associate professor of clinical family medicine at the University of Southern California.
The Affordable Care Act established health insurance marketplaces, including Healthcare.gov and state exchanges at which people could sign up for coverage and potentially qualify for federal subsidies. Despite initial spikes in prices on the marketplace, premiums have grown more affordable over the last couple of years.
"The tax credits have proven to be a very stabilizing force in the individual market," Eibner said.
More than 20 million Americans gained health insurance under the ACA. Black Americans, children and small-business owners have especially benefited.
Thirty-seven states have expanded Medicaid, deepening their pool of eligible residents to those who live at or below 138% of the federal poverty level. As a result of the increased access to health care, it's estimated that more than 19,000 lives have been saved.
The Medicaid expansion is popular with voters. After Louisiana Gov. John Bel Edwards, a Democrat, won reelection in November, his lead pollster told The Washington Post that "no single issue was more important than the Medicaid expansion."
More than 90% of the expenses states pick up under their Medicaid expansion are reimbursed by the federal government. The Medicaid expansion in Connecticut has reduced the state's per-person spending on the program by nearly 6%, even while it brought on an additional 200,000 people.
That math has led even red states that criticized the Affordable Care Act to eventually adopt it, Stevens said. "It was increasingly tough to leave federal money on the table," he said.
There are other parts of the ACA with bipartisan support, including prohibiting insurers from denying coverage or charging more to people with preexisting conditions. More than 1 in 4 Americans report having a preexisting condition such as asthma or high blood pressure.
"Many key provisions of the Affordable Care Act remain because they are so popular with voters," said Summer Johnson McGee, the dean of the School of Health Sciences at the University of New Haven in Connecticut.
Other powerful changes of the Affordable Care Act don't fit neatly into sound bites.
The law prohibited health insurers from including lifetime and annual caps in their plans. In the past, the government estimates that more than 20,000 people hit those limits each year.
"It was horrible," said Laurel Lucia, director of the Health Care Program at the University of California Berkeley's Center for Labor Research and Education. "Just when you've been hit with a really serious health condition, you're not covered fully."
The Affordable Care Act also banned insurers from charging rates based on gender. Prior to its passage, one study found that young women were charged up to 45% more than young men for their health insurance.
Under the ACA, Medicare stopped reimbursing hospitals for the treatment of hospital-acquired infections. "Prior to this, if you picked up an infection, the hospital earned more money," Stevens said. As a result, the number of such infections have plummeted and 125,000 fewer deaths have occurred.
"Early diagnosis of cancer increases the probability of successful treatment and can lead to fewer cancer deaths, better outcomes for patients and lower costs of treatment," Soni said.
Yet there are problems — old and new.
Health-care spending still makes up nearly a fifth of the country's gross domestic product. "The ACA, in the last 10 years, has largely failed on reducing overall spending," Johnson McGee said.
Many Americans can't afford to take care of themselves. The average employer-sponsored insurance has annual family premiums over $20,000. One study found that more than 40% of Americans are struggling with medical bills or debt, and health-care expenses continue to be a leading cause of bankruptcy.
"While the ACA succeeded in creating a situation in which nearly the entire population either has, or can get, health insurance, it did nothing to reduce the underlying cost of medical care," said Ed Haislmaier, a health-care policy expert at the Heritage Foundation.
The Trump administration has been hostile toward the Affordable Care Act.
The overhaul of the tax code in 2017 repealed the individual mandate penalty. That central provision of the Affordable Care Act required every American to sign up for health insurance or face a tax penalty. A family of four could pay more than $13,000 for going uninsured. The administration has also slashed the Affordable Care Act's marketing budget by 90%. Advocates say it's now harder for people to learn about their health insurance options.
These changes are likely among the reasons 400,000 fewer people signed up for health insurance on the marketplace in 2019 than in 2018. Between 2017 and 2018, the number of uninsured children swelled by 100,000.
Since more than a dozen states continue to refuse to adopt the Affordable Care Act's Medicaid expansion, 2.5 million people who would have been eligible remain uninsured. In Texas, one of the states that hasn't expanded Medicaid, nearly 1 in 5 people live without health insurance.
Meanwhile, it could become harder to qualify for Medicaid in some places.
"There's a lot of people who have health problems that prevent them from working," said Linda Jordan, a public benefits lawyer at the Center for Civil Justice in Michigan. Starting in January, many Medicaid recipients in Michigan will have to show at least 80 hours a month of workforce engagement to maintain their coverage.
Other states, meanwhile, have fully adopted the Affordable Care Act — and gone further to cover their residents.
In 2020, California will become the first state to offer state subsidies to people who earn too much to qualify for federal tax credits on the health-care marketplace. For example, an individual earning $70,000 a year and a family of four making $150,000 could qualify for the state relief.
The Affordable Care Act required insurers to cover dependents until their 26th birthday. Yet in New Jersey, some dependent, unmarried adults are eligible to stay on their parents' plan until they're 31.
And while the federal government no longer fines the uninsured, California, New Jersey, Rhode Island, Vermont, Massachusetts and Washington, D.C., still penalize their uncovered residents.
Washington state signed into law this year a public option for health insurance. Two front-runners for the Democratic presidential nomination — Sens. Bernie Sanders, I-Vt., and Elizabeth Warren, D-Mass. — are campaigning on "Medicare for All." And today, 6 in 10 Americans believe it's the government's responsibility to make sure all Americans have health-care coverage.
Not long ago, Lucia said, such developments would be unthinkable.
"I think the Affordable Care Act has been a game changer in terms of public support for health care as a right," she said.