One year ago today, President Obama signed the federal health care legislation into law. “Today we are affirming that essential truth, a truth every generation is called to rediscover for itself, that we are not a nation that scales back its aspirations,” Obama said at the bill signing.
But in the twelve months after its passage, "scale back" has been the name of the game in the rhetoric around the new law, whether in GOP-led efforts to the bill, in two pivotal court decisions, or in the president's own support for giving states more flexibility. But through it all, the health insurance overhaul remains intact and continues to incrementally roll out into the lives of Americans.
The Political Pushback
Almost immediately after the Affordable Care Act — or Obamacare, depending on your politics — was passed, it became a political flashpoint. The relentless, wonky policy debate moved from Congress into the courts and onto the campaign trail.
Opponents of the law pursued a legal strategy by filing in federal courts, resulting in decisions that have already started coming in. Three federal judges have upheld the law, but the requirement that every American have health insurance did not pass muster with two federal judges.
One in Virginia ruled last December that the individual mandate provision itself is unconstitutional. A Florida judge went further and struck down the entire law in a case brought by 26 of the 50 states. Earlier this month, the Obama administration asked the appeals judge in Georgia to move up scheduling for his review, speeding up its likely path to consideration by the U.S. Supreme Court.
Repealing health care was also a persistent and pervasive talking point during the midterm elections. After their sweeping victories at the polls, Republicans ousted House Speaker Nancy Pelosi and the Democratic leadership who'd guided the legislation through passage. Weeks after taking office, all 85 GOP freshman supported a resolution, in the words of the new majority, “Repealing the Job-Killing Health Care Law.”
That symbolic vote stopped short in the Senate, but the American public continues to have very mixed feelings about the law. Right after the health care package became law, slightly more Americans viewed the law favorably than not, but that swung the other way in a poll this month by Kaiser that found forty-six percent of adults have an unfavorable opinion of the law. Still, while sharply divided arguments have dominated the political debate, “confused” summed up feelings about the law for 53 percent of respondents.
What it Means for Your State
In 2014, all states will be required to expand their Medicaid programs to cover all low-income adults, whether or not they have children. Some states, like Connecticut and Minnesota, have already expanded their rolls. Arizona, on the other hand, wants to stop covering childless adults, and the Obama administration told the governor it could do so without losing federal funds.
That's just one state that has serious worries over the required expansion, especially at a time when current Medicaid costs are make up such a large share of deficit-plagued budgets at the state level. In Texas, Republican Governor Rick Perry went so far as to float that his state should drop the program altogether, before a state report soundly rejected that idea as unwise for patients, hospitals and county budget. Now, like other states, Texas is seeking permission from the federal government to scale back its Medicaid coverage.
States have already set up new health plans to cover high-risk patients who can’t get insurance, filling the gap until the ban on canceling any policies because of preexisting conditions takes effect in 2014. Enrollment in these new plans has been slow, though. After the roll-out last summer, there were just 8,000 in the plans in November. By February, the Obama administration was touting that enrollment "increased by 50 percent," to a total of just over 12,000. (Federal officials estimate 350,000 Americans are eligible for the plans.)
In New York, just 766 New Yorkers have joined the new plan, and Sara Collins, a health policy analyst with the Commonwealth fund, blames cost. The plans are subsidized to account for the potential health care costs from the at-risk clients – the plan costs $362 or 421 per month, depending on where in New York patients live – but enrollees have to cover the full premium on their own. For many people, it's just too expensive,” Collins said. “And so people who are lower income and really needing those plans may simply not be able to afford them.”
Obama on Defense
State budget troubles have pushed the Obama administration to emphasize ways that states can scale back their health programs, just a few years before every American is required to be insured. Health and Human Services Secretary Kathleen Sibelius wrote a letter in February to governors to outline ways they could cut their Medicaid programs without federal approval.
President Obama went further when he he spoke to a gathering of governors. He told them he was willing to back off of the centerpiece of the health care law, the requirement that all Americans have insurance coverage by 2014, if states can come up with alternative plans that would expand coverage at the same cost. As passed, states can opt out of the requirement, known as the individual mandate, after three years, if their plan gets federal approval. Now, the president said he supports allowing states to do opt out immediately in 2014 if they think they've found a better way, like in Massachusetts, where there is already a insurance mandate in place.
It was a nod to governors who worry about the looming costs when the requirements go fully into effect in 2014, but it's a change that requires approval by lawmakers that are divided on not just fixes to the law, but whether it should exist at all.
That's a debate Obama wants to avoid. He told the governors he continues to be open to proposals to update the massive legislation, but he said, “I am not open to refighting the battles of the last two years or undoing the progress we’ve made."
What it Means for You
Finally, if you are a healthy, insured adult over 27, you probably haven't noticed much of anything. If you've been to the doctor for an annual check-up, you may have noticed it's now free. That's because all health plans must now offer a yearly preventative visit, mammograms and colonoscopies at no cost.
New rules have already rolled out for young adults, children who’ve been sick, or the seriously chronically ill. Starting last September, adult children could stay on their parents health insurance plans until age 26. Insurance companies can no longer deny coverage to children based on a preexisting condition. And in a reprieve for chronic illnesses that are expensive to treat, new health insurance plans can no longer have a lifetime cap and insurance companies can also no longer rescind policy unless there is proof of fraud.
A myriad of other changes roll out this year and next — see this see this very handy timeline from the Kaiser Family Foundation — but the real fireworks come in 2014, the real go-time for this massive overhaul, if you still have your insurance, you still might not notice much.
If you’re uninsured, 2014 is when you’re required to buy in. Where and how you’ll get your new coverage depends on your income level, marital status, and number of kids. To see how it might work for you, and what penalties you’ll have to pay if you don’t land a plan, it’s worth dusting off this Washington Post guide from a year ago.
Because despite all the talk about repealing, scaling back or striking down, this massive, complicated package of new laws is, for the most part, the same as it was a year ago.