Checking in on 14 Years of Obamacare; Part 2

Health and Gender Policy Brief #172 | By: Geoffrey Small | April 01, 2024

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March 2024 highlights fourteen years since The ACA (Affordable Care Act) has been enacted. When it was passed more than a decade ago, there were three primary goals of the ACA, or more popularly referred to as Obamacare. According to, the first was to make affordable health insurance more available for the American public. The second goal was to encourage states to expand their Medicaid coverage to all individuals whose income is significantly below the federal poverty level. Finally, the ACA would provide federal support to “innovative medical care delivery methods designed to lower the costs of health care generally.” This part in the series will analyze the ACA’s impact on the expansion of Medicaid coverage in each state.

Policy Analysis

Medicaid, along with Medicare, was introduced during the Social Security Amendments of 1965. Medicare is a federal health insurance program that covers everyone over the age of 65, and some people who suffer from specified disabilities or conditions. Medicaid is a joint federal and state program that provides coverage for individuals who have a low enough income to qualify. Medicaid funding works by states accepting matched federal funding upon agreeing to baseline healthcare coverage standards that the federal government establishes. Even though Medicare was universally established and administered in 1965, states had to agree to opt into Medicaid to receive matched funding from the federal government. By 1982, all states agreed to offer the baseline Medicaid program. When the ACA was introduced, the individual market was significantly overhauled. The ACA required that all U.S. citizens have healthcare coverage, or face a financial penalty, while insurers had to provide coverage for essential health needs regardless of pre-existing conditions. These policy changes required states to administer an expanded Medicaid market for previously uninsured individuals and those having coverage hardships due to pre-existing conditions.

Checking in on 14 Years of Obamacare: Part 2

Photo taken from KFF (Kaiser Family Foundation)

A recent Kaiser Family Foundation study concluded that 10 states have not fully adopted the ACA’s expanded coverage requirements. As of March 20th, 2024, Wyoming, Texas, Wisconsin, Kansas, Tennessee, Florida, Mississippi, Alabama, Georgia, and South Carolina have not adopted all of the expanded requirements under the ACA. The KFF study indicates many of these states still have a strong opposition to withdrawing work requirements from their Medicaid coverage guidelines. In 2017, the Trump administration notified state governors that the 1115 waiver under the 1965 Social Security Amendments can be used to establish work-requirement policies in order for individuals to qualify for Medicaid. This waiver was originally designed for states to develop innovative policies in advancing Medicaid coverage that may conflict with federal regulations.

The Affordable Care Act is considered a massive overhaul of our healthcare system. A 14-year debate has since ensued between scholars, policymakers, and the mainstream media related to the three primary goals. Within each goal lies nuanced data detailing the progress our society has made since the law was passed. Studies show the ACA expansion of Medicaid standards have directly impacted the reduction of previously uninsured individuals. Some states still refuse to apply the expansion implemented by the ACA. The Trump administration’s changes to the 1115 waiver were designed to allow some states to restrict their Medicaid access. However, the Biden administration has worked to reverse the Trump administration changes to the 1115 waiver, which undermined ACA expansion, by denying new work waiver applications from states and legally challenging existing state legislation for work requirements.

For Part 1 of the Obamacare series, click here.

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