If only I had known what was ahead when I got into the health insurance industry in the early 2000s.
1: Declining uninsured individuals.
Back in 1999, when I was still in college, around 42.1 to 42.6 million Americans were without health insurance. That represented about 15-17% of the nation’s population. While that sounds like a substantial number, it actually was down from 43.9 million uninsured Americans in 1998.
By 2010, just before the Affordable Care Act (ACA) was signed into law, the number of uninsured persons in the U.S. had risen to 48.2 million, about 18.2% of Americans. In 2013, the year most ACA provisions took effect, the number was slightly lower: 44.3 million and 16.6% of the total population.
In three years, the uninsured ranks declined significantly. Just 10.4%, about 28.2 million Americans, were without health insurance in 2016. Since that time, the uninsured number has been both up and down. A December 2024 report showed 7.6% of Americans, or 25.3 million, lacked insurance in mid-2024.
2. The ACA protects people with pre-existing health conditions.
While it’s possible the 119th Congress (which began service in January 2025) could make changes to the ACA, it currently includes a guaranteed issue provision that forbids discrimination in health programs and activities. It also prohibits health insurance companies from refusing coverage (or charging more) because of an individual’s health problems that pre-date their ACA-compliant coverage. Insurers can also not limit benefits for conditions like asthmas, diabetes, cancer, pregnancy, and others. Once a person has insurance, their health plan cannot refuse to treat or cover pre-existing conditions. For additional information, visit HealthCare.gov. For additional information, visit HealthCare.gov.
3. Lower-income individuals can get health coverage through the expansion of Medicaid.
The ACA permits states to expand Medicaid to offer health coverage to lower-income adults. The expansion includes those with incomes of up to 138% of the federal poverty level. As of November 2024, 41 states have signed on to Medicaid expansion. That includes California, which operates its Medicaid program as Medi-Cal, and Nevada. In 2026, Nevada will further expand its program to permit more counties in the state to participate.
4. All ACA-compliant health plans include coverage for 10 Essential Health Benefits (EHBs). These EHBs are:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital).
- Emergency services.
- Hospitalization (like surgery and overnight stays).
- Pregnancy, maternity, and newborn care (both before and after birth).
- Mental health and substance use disorder services, including behavioral health treatment, counseling, and psychotherapy.
- Prescription drugs.
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills).
- Laboratory services.
- Preventive and wellness services and chronic disease management.
- Pediatric services, including oral and vision care.
Plans must also include birth control and breastfeeding coverage.
Essential health benefits are minimum requirements for all Marketplace plans. Specific services covered in each broad benefit category can vary based on state requirements. Plans may offer additional benefits, such as dental and vision as well as medical management programs (for weight management, back pain, and diabetes).
5. Health care is more affordable under the ACA.
Some may suggest that this is not really the case; however, for many, especially those enrolled in health insurance through the ACA Marketplace, it is true. The premium tax credits available to individuals and families through the ACA help make insurance more affordable for millions of Americans.
The ACA has positively impacted the small business health insurance marketplace, too. Small businesses can now take advantage of the Small Business Health Options Program (SHOP) to purchase health and dental coverage for their employees. Employers with 50+ full-time workers must offer health insurance.
Small businesses and their employees are no longer subject to medical underwriting for health insurance. Insurers are required to guarantee issue coverage to small groups (California employers with 1-100 full-time employees and Nevada employers with 1-50 full-time employees).
Prior to the ACA, women were charged more for health insurance than men. In the individual marketplace, women could be charged up to 1.5 times the rate for men. In addition, insurers often treated pregnancy as a pre-existing health condition that could be the basis for denying coverage. The ACA eliminated that gender rating and discrimination based on a pre-existing health condition.
Today, more than 60 million nationwide have access to preventive services as well as other benefits without cost sharing.
6. Young adults have greater access to insurance and care.
The ACA gives young adults the opportunity to stay on their parents’ health insurance until age 26. The result is more than two million more young adults with coverage. That’s important since many in this age group are less likely to have coverage through their jobs than their older counterparts.
In addition, the expansion of Medicaid, mentioned above, has allowed more children in low- and middle-income families to access health care. It’s estimated that up to one-third of new Medicaid enrollees are children.
7. The ACA improved access to prescription drugs.
Before the ACA, nine percent of individual market plans did not include any coverage for prescription medications. The ACA requires marketplace plans to “cover at least one drug in each drug class” and to include out-of-pocket Rx expenses in an insured person’s or family’s deductible. Expanded Medicaid eligibility and the expansion of Medicaid’s drug rebate program gives more lower-income Americans access to brand-name and generic drugs. And it does so at a lower cost to taxpayers.
8. Reduced costs for seniors on Medicare.
ACA programs have reduced prescription drug costs for older Americans by more than $20 billion. These programs have also benefited seniors through no-cost preventive care services like wellness visits and cancer screenings. The Medicare “donut hole” has been gradually eliminated by the ACA. Today, all Medicare plans include a cap of $2,000 on what a Medicare enrollee will pay out of pocket for covered prescription drugs.
9. More health care reform is likely.
As health care costs and the cost of insurance continue to escalate, all of us can expect to see more proposals for health care reform. Proposals by the incoming Trump administration and GOP members of Congress could end current ACA subsidies, which will increase the number of uninsureds nationally. States may try to respond with their own plans for universal health care. In California and a few other states, multiple efforts have failed, undermined by projected costs.
The bottom line: The Affordable Care Act has changed the way many Americans get their health care, what they pay for health insurance, and what’s covered by their health plans when seeking care.
The ACA was not something I could have foreseen when I first entered the health insurance industry 20 years ago. More change is inevitable. I urge you not to be discouraged. We have seen many changes over the years, but, overall, things are better today than in the past.
Different facets of our business are affected by state insurance regulators, while others are driven by activities in Washington, D.C. Our industry trade groups – like the National Association of Benefits and Insurance Professionals (NABIP) – and their affiliated chapters are monitoring D.C. and state proposals. Join NABIP now, or find a local chapter.Sign up and stay tuned for updates from these associations and from Word & Brown.
About the Author: Peter Nill is a 20+ year veteran of the health insurance industry. He is Director of Field Sales for the Los Angeles and Nevada regions at Word & Brown General Agency.
