Obamacare Marches On, Step by Step

THE AFFORDABLE CARE ACT, which has now been the law of the land for five years, is beginning to reshape the national landscape in significant ways.

According to a New York Times analysis of the ACA’s first enrollment period, about 10 million additional people gained insurance in 2014. Many of them fall into demographic groups that have historically struggled to access coverage, such as low-income Americans, people of color, and women. Ultimately, President Obama’s health law is slowly making the country more equal.

There are a few ways the ACA is accomplishing that goal. It has built-in consumer protections to ensure that insurance companies treat people more fairly. It’s created state-level marketplaces to give people new options for purchasing private plans. And it’s expanded the pool of people who are eligible for public coverage through the Medicaid program.

Health policy experts agree that adding more low-income people to the Medicaid rolls represents one of the biggest successes of the ACA so far. According to the Urban Institute, a nonprofit research group, the states that agreed to expand their Medicaid programs—27 so far, plus the District of Columbia—have seen about a 40 percent drop in their uninsured rates.

“This has been a lifesaver for me. I hadn’t seen a doctor for 11 years,” Marc Sigoloff, a freelance writer in Illinois, told me. Sigloff signed up for Medicaid and subsequently discovered he had a brain tumor.

Carol Fisher Hardaway is now covered through Maryland’s Medicaid program. She told me she has a newfound peace of mind since she doesn’t need to worry about affording the treatment for her multiple sclerosis. Her reduced stress, in fact, is quantifiable. When we talked in October, she had just found out her blood pressure was at a healthy level for the first time in nearly 15 years.

“I sat in the parking lot and cried,” she said. “I’m so blessed, and obviously my body is grateful. I’m grateful I’m able to benefit from it.”

But not everyone shares Sigloff and Fisher Hardaway’s gratitude. After the health-care reform law was passed, the Supreme Court ruled that its Medicaid expansion provision should be optional. That ruling allowed anti-ACA states to block this particular piece of the law—stranding an estimated 4 million Americans in a “coverage gap,” according to a Kaiser Family Foundation researcher.

Over the past year, faith leaders in states from Missouri to Ohio to Tennessee have raised Medicaid expansion as a moral issue, arguing that it is the moral responsibility of lawmakers to protect their most vulnerable citizens.

“History has not been kind to governors who stand in front of schoolhouse doors because the children are not the right kind of children, and history will not be kind to governors who stand in front of hospital doors and clinics because people who are trying to get in are deemed politically dispensable,” Rev. Raphael Warnock, senior pastor at Atlanta’s Ebenezer Baptist Church, told reporters in May.

Nonetheless, the Medicaid expansion situation remains largely unchanged. Although health-care advocates hoped the midterm elections might usher in more government leaders who support the Medicaid expansion, that wasn’t the case.

As long as states resist expansion, the ACA won’t fully accomplish its goal of extending coverage to the people who can’t currently afford it. And we will only be able to see the full effect of the law in about half of the country—no matter how many years pass under Obamacare.