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Most Americans may be unaware of the significant impact the Affordable Care Act (ACA) has had on nearly the entire U.S. health insurance system.
Fifteen years ago, when Congress passed the ACA (officially the Patient Protection and Affordable Care Act), journalists and consumers recognized that the law provided Americans with health insurance choices that were previously nonexistent.
This story is the second in a series. Read the first here.
By signing the ACA into law on March 23, 2010, former President Barack Obama ushered in measurable improvements in health insurance, not only for ACA enrollees but also for those on Medicare, Medicaid and those who got insurance from employers.
In the first part of this series, we covered four of the ACA’s most significant changes. The law:
Beyond those four significant improvements, the ACA also required:
When it became fully effective in 2014, the ACA allowed consumers to shop for coverage on a public exchange (called the ACA marketplace) where for the first time, they could compare and choose health insurance plans from multiple insurers in their state. Almost all of those insurers were required to include 10 essential health benefits (EHBs) in every health plan.
Only plans that were grandfathered or grandmothered under the ACA do not need to provide the essential benefits, wrote Louise Norris, a health reform analyst and health insurance agent in Wellington, Colo., who writes for healthinsurance.org. Grandfathered and grandmothered plans are those in effect before 2014 and have not changed significantly since then.
Outside of the ACA, not all health insurance plans cover the 10 EHBs, Norris wrote, adding that they can vary from state to state. To establish EHBs, each state designates a benchmark health plan that includes those 10 benefits, she added. Although the ACA’s EHB categories are the same in every state, what individual and small-group health plans cover will vary among states, she explained.
“The ACA outlined the essential health benefits as broad categories of care, and each state can define exactly what needs to be covered in each essential health benefit category,” she added.
All new individual and small-group health insurance policies (including those sold in the ACA’s health insurance exchanges and off-exchange) must cover the following EHBs for all enrollees:
For EHBs, the law prohibits health insurers from setting annual or lifetime limits on the amounts they pay for these services. But insurers can cap the number of covered visits for certain services, such as physical therapy, Norris explained.
One of the most significant consumer protections under the ACA was the provision called guaranteed issue. This requirement prohibited insurers from denying or limiting coverage based on gender or pre-existing conditions.
When the law became fully effective on Jan. 1, 2014, all individual and group health plans were required to issue policies to all applicants, regardless of their health status or health history, according to this KFF report in 2012. Previously, only five states had such coverage guarantees: Maine, Massachusetts, New Jersey, New York, and Vermont.
“In the vast majority of the country, if you were buying your health insurance, your medical history was relevant,” Norris explained in an interview. “That meant you could either get rejected altogether, or you could get accepted but with a higher premium based on your medical history. Or, they could just exclude your pre-existing conditions from coverage.”
For families who rely on health insurance through an employer, the ACA included a provision letting young adults stay on their parent’s insurance until age 26. About 30% of young adults in this group are uninsured and represent about 20% of all uninsured Americans, according to the federal Centers for Medicare and Medicaid (CMS). Adults in this age group have the highest rate of being uninsured (30%) among any age group, CMS added.
Before the ACA, health plans often dropped young adults from their parents’ policies, leaving many college graduates and students uncovered, CMS added. Under a common myth, many believe young adults don’t need health insurance, but one in six has a chronic illness such as cancer, diabetes or asthma and almost half of uninsured young adults have trouble paying medical bills, CMS added.
As a result of the ACA, Medicare, Medicaid and employer-sponsored health insurance provide more substantial coverage now than they did before the ACA became fully effective in 2014. For example, those who have health insurance through their employers benefit from ACA’s Section 2713, which requires private health plans to provide coverage for a range of recommended preventive services and may not impose cost-sharing (copayments, deductibles or co-insurance), KFF explained in this report. Medicare and Medicaid now cover most of those same preventive services.
Also, the law required employers to beef up their insurance coverage for workers, by requiring large employers to provide health insurance for those who work at least 30 hours a week, Norris said in an interview. “Most large employers were already providing health insurance benefits, but under the ACA if they did not offer real health insurance, they could face financial penalties. Before the ACA, there were no such penalties and no one was keeping track of what employers offered.”
The ACA provisions affecting employers are significant because employer-sponsored health insurance is the largest source of health coverage for non-elderly Americans, according to this report from KFF. “Overall, 60.4% of people under age 65, or about 164.7 million people, had employment-sponsored health insurance in 2023,” KFF reported.
In part three of this series, we will continue to list the significant ways the ACA improved health insurance, and in part four, we’ll explain that the ACA is like many other laws: It does some good but it’s imperfect. 
Joseph Burns
Joseph Burns is AHCJ’s health beat leader for health policy. He’s an independent journalist based in Brewster, Mass., who has covered health care, health policy and the business of care since 1991.
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