On March 23, 2010, then-U.S. president Barack Obama signed the Patient Protection and Affordable Care Act into law, otherwise known as ACA or Obamacare. At the time the health reform was introduced, nearly 50 million people had no health insurance – or one out of every six Americans. That was by far the most miserable performance among healthcare systems in developed countries. More surprising because the United States has the highest spending on health as a percentage of GDP, at almost 17 percent. For perspective, Australia’s health consumed around nine percent and Germany’s around 11 percent of their respective national GDPs. Per capita, the U.S. spent twice as much as comparable developed countries. The previous health coverage system also allowed insurers to refuse coverage for a person if they had a pre-existing condition. These factors led to a fragile healthcare system and an insecure life for many non-affluent people. Thus, it is no wonder that according to some surveys during 2008, over 80 percent of Americans demanded an overhaul of the healthcare system.
Aims and accomplishments
The main aims of the ACA are increasing access to affordable, quality healthcare and reducing the rising U.S. health expenditures. To achieve this, many health reforms were needed. These can be broadly categorized into reforms on healthcare coverage and access and reforms of the healthcare payment and delivery system. Most importantly the ACA expanded Medicaid eligibility, created health insurance exchanges (otherwise known as ACA marketplaces), mandated health insurance for all (or face a tax penalty), and protected those with pre-existing health conditions from being charged more or being refused coverage by insurance companies. As of 2023, roughly 40 million individuals now benefit from ACA-related enrollment in health care programs such as Medicaid or purchased from the Marketplace. Not only has this driven down the rate of uninsured, but numerous studies have reported the positive impact of Medicaid expansion. One such study estimated that just during the four years after 29 states expanded Medicaid, roughly 19.2 thousand lives were saved from treatable conditions (such as heart disease and diabetes). Another focus of health policy makers, before moving on to larger goals such as Medicare-for-all or single-payer systems, is reducing high cost-sharing and deductibles. Surveys show that while the share of uninsured has decreased, instead there is an increase of those who are insured but effectively underinsured because their out-of-pocket health costs are still too high and unaffordable compared to their income.
Flaws
A health reform as large as the ACA is of course not without its flaws. One of these is the Medicaid ‘coverage gap’. When the ACA was first written into law, it was expected that all Americans with household income up to 138% of federal poverty level (FPL) would receive coverage under Medicaid, thus only those earning between 100%-400% FPL were eligible for ACA marketplace subsidies (also known as premium tax credits). However, in 2012, the supreme court ruled that states were allowed to decide whether they will expand Medicaid or not, and currently (as of the end of 2021) 12 states still have not expanded Medicaid. Therefore, there are an estimated 1.9 million people in these non-expansion states that earn too much to be eligible for Medicaid in their state (average eligibility is 40% FPL, or roughly 580 U.S. dollars per month for a household of two), but less than 100% FPL and therefore ineligible for marketplace subsidies. Moreover, without expansion, childless adults are also ineligible for Medicaid, no matter how low their income is, yet adults living alone represent the highest share of those uninsured. The Biden-administration is doing what it can to encourage the remaining states to expand Medicaid through the American Rescue Plan Act of 2021, which provides further temporary fiscal incentives. Another issue is the 'family glitch,' which prevented families with employer-sponsored coverage from receiving financial assistance for Marketplace coverage. Until 2023, the affordability of an employer-sponsored health plan was decided only by the cost of the employee, with no consideration given to the cost of adding family members. According to the KFF analysis, the family glitch rendered 5.1 million Americans ineligible for marketplace subsidies. This is set to change from 2023, since the IRS has introduced a new regulation to replace a 2013 IRS policy that caused the "family glitch".
Opposition and public opinion
The ACA remains a much debated topic in the United States. Originally, even the term ‘Obamacare’ was used by opponents of the law in a pejorative way. Many conservatives see it as a governmental takeover of the healthcare system, portraying it in an un-American, unconstitutional, and even ‘socialist’ light. Opponents were willing to spend around 420 million dollars on TV ads to portray the law negatively, while only 27 million dollars were spent supporting the new law. For seven years, the republicans have campaigned the repeal and replacement of Obamacare, yet when they finally had the authority to execute their plans in 2017, they failed. This was largely due to opposing views within the party – because many republican legislatures actually liked parts of Obamacare such as the protection against preexisting conditions – and most importantly because of a lack of a clear replacement plan. Because in spite of its flaws, the ACA has indisputably achieved increased coverage and every republican plan so far would have decreased coverage while increasing premiums or deductibles for many. However, the Trump-administration did leave marks, such as rendering the individual mandate null, meaning there was no monetary punishment for people foregoing health insurance. This was thought to bring about the collapse of the ACA’s ‘three-legged stool’ approach. While there was indeed a rise in the percentage of uninsured after 2017, overall, the system has held steady. Other laws enacted to decrease Medicaid advertisem*nt funding or reduce the open-enrollment period among others, have also been slowly reversed by Biden’s administration. Since the beginning, public opinion about the health reform has been very mixed, although those seeing the ACA favorably has finally reached a stable majority.
This text provides general information. Statista assumes no liability for the information given being complete or correct. Due to varying update cycles, statistics can display more up-to-date data than referenced in the text.
Preeti Vankar Junior Researcher
Key insights
- Number of Americans benefitting from ACA
- 45m
Detailed statistics
Number of ACA-related enrollments in the U.S. 2014-2024
- Percentage of Americans with any health insurance
- 92.1%
Detailed statistics
Percentage of U.S. Americans with any health insurance 1990-2022
- Total Medicaid enrollment
- 90.8m
Detailed statistics
Total Medicaid enrollment 1966-2022
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Introduction: high uninsured rates before ACA
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- Basic Statistic Number of people in the U.S. without health insurance 1997-2023
- Premium Statistic Percentage of people in the U.S. without health insurance 1997-2023
- Premium Statistic Percentage of U.S. Americans with any health insurance 1990-2022
- Premium Statistic Share of people in the U.S. without health insurance by age 1997-2023
- Premium Statistic Share of U.S. adults without health insurance by poverty level 2019-2023
Introduction: high uninsured rates before ACA
- Basic Statistic Number of people in the U.S. without health insurance 1997-2023
Number of people in the U.S. without health insurance 1997-2023
See AlsoThe Patient Protection and Affordable Care Act: Implications for Public Health Policy and PracticeOverview of the Affordable Care Act and MedicaidPatient Protection and Affordable Care Act - GlossaryTypes of Obama Care Plans in CA | Health for CaliforniaNumber of people without health insurance in the United States from 1997 to 2023 (in millions)
- Premium Statistic Percentage of people in the U.S. without health insurance 1997-2023
Percentage of people in the U.S. without health insurance 1997-2023
Percentage of people without health insurance in the United States from 1997 to 2023
- Premium Statistic Percentage of U.S. Americans with any health insurance 1990-2022
Percentage of U.S. Americans with any health insurance 1990-2022
Percentage of people with any health insurance in the United States from 1990 to 2022
- Premium Statistic Share of people in the U.S. without health insurance by age 1997-2023
Share of people in the U.S. without health insurance by age 1997-2023
Share of people without health insurance in the United States from 1997 to 2023, by age
- Premium Statistic Share of U.S. adults without health insurance by poverty level 2019-2023
Share of U.S. adults without health insurance by poverty level 2019-2023
Share of adults aged 18-64 years without health insurance in the United States from 2019 to 2023, by family income as a percentage of FPL
Current picture: Medicaid expansion vs non-expansion states
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- Premium Statistic Share of U.S. adults without health insurance by Medicaid expansion status 2010-2023
- Premium Statistic U.S. adults with public health insurance by Medicaid expansion status 2010-2023
- Premium Statistic U.S. adults with private health insurance by Medicaid expansion status 2010-2023
- Basic Statistic Uninsured U.S. children distribution and rate by Medicaid expansion status 2020
- Basic Statistic Medicaid income eligibility limits as % FPL as of Jan 2024, by state expansion status
Current picture: Medicaid expansion vs non-expansion states
- Premium Statistic Share of U.S. adults without health insurance by Medicaid expansion status 2010-2023
Share of U.S. adults without health insurance by Medicaid expansion status 2010-2023
Share of adults aged 18-64 years without health insurance in the United States from 2010 to 2023, by state Medicaid expansion status
- Premium Statistic U.S. adults with public health insurance by Medicaid expansion status 2010-2023
U.S. adults with public health insurance by Medicaid expansion status 2010-2023
Share of adults aged 18-64 years with public health insurance in the United States from 2010 to 2023, by state Medicaid expansion status
- Premium Statistic U.S. adults with private health insurance by Medicaid expansion status 2010-2023
U.S. adults with private health insurance by Medicaid expansion status 2010-2023
Share of adults aged 18-64 years with private health insurance in the United States from 2010 to 2023, by state Medicaid expansion status
- Basic Statistic Uninsured U.S. children distribution and rate by Medicaid expansion status 2020
Uninsured U.S. children distribution and rate by Medicaid expansion status 2020
Distribution and rate of children without health insurance in the U.S. in 2020, by state Medicaid expansion status
- Basic Statistic Medicaid income eligibility limits as % FPL as of Jan 2024, by state expansion status
Medicaid income eligibility limits as % FPL as of Jan 2024, by state expansion status
Median Medicaid income eligibility limits for children and adults as a percent of the Federal Poverty Level (FPL) as of May 1, 2024, by state expansion status
Current picture: areas of improvement
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- Basic Statistic Number of uninsured U.S. adults in the Medicaid coverage gap in 2021
- Basic Statistic Distribution of U.S. adults in the Medicaid coverage gap in 2021, by state
- Basic Statistic Number of uninsured U.S. adults in the Medicaid coverage gap in 2021, by state
- Basic Statistic Number of U.S. people in the 'family glitch' in 2019, by select demographics
- Basic Statistic Share of U.S. people in the 'family glitch' in 2019, by select demographics
- Basic Statistic American Rescue Plan removes ACA subsidy cliff for two years starting 2021
Current picture: areas of improvement
- Basic Statistic Number of uninsured U.S. adults in the Medicaid coverage gap in 2021
Number of uninsured U.S. adults in the Medicaid coverage gap in 2021
Number of non-elderly uninsured adults in non-expansion states who would be eligible for Medicaid if their states expanded Medicaid as of 2021 (in thousands)
- Basic Statistic Distribution of U.S. adults in the Medicaid coverage gap in 2021, by state
Distribution of U.S. adults in the Medicaid coverage gap in 2021, by state
Distribution of adults in the Medicaid coverage gap in the United States in 2021, by state
- Basic Statistic Number of uninsured U.S. adults in the Medicaid coverage gap in 2021, by state
Number of uninsured U.S. adults in the Medicaid coverage gap in 2021, by state
Number of non-elderly uninsured adults in non-expansion states who would be eligible for Medicaid if their states expanded coverage as of 2021, by state and current eligibility
- Basic Statistic Number of U.S. people in the 'family glitch' in 2019, by select demographics
Number of U.S. people in the 'family glitch' in 2019, by select demographics
Number of dependents that fall in the 'family glitch' in the U.S. in 2019, by insurance coverage, income, gender, and age (in thousands)
- Basic Statistic Share of U.S. people in the 'family glitch' in 2019, by select demographics
Share of U.S. people in the 'family glitch' in 2019, by select demographics
Percentage of dependents that fall in the 'family glitch' in the U.S. in 2019, by insurance coverage, income, gender, and age
- Basic Statistic American Rescue Plan removes ACA subsidy cliff for two years starting 2021
American Rescue Plan removes ACA subsidy cliff for two years starting 2021
ACA subsidy cliff: health insurance premiums as percent of income among U.S. adults of 60 years with average Silver Plan under the ACA vs COVID-19 Relief Law in 2021
Positive impact of ACA
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- Basic Statistic Number of studies that find positive effects of Medicaid expansion as of 2021
- Basic Statistic Number of ACA-related enrollments in the U.S. 2014-2024
- Basic Statistic Impact of Medicaid expansion on mortality in the U.S. 2014-2017
- Basic Statistic Impact of Medicaid expansion on mortality in the U.S. 2014-2017, by state
- Basic Statistic Traditional Medicaid savings from Medicaid expansion in select U.S. states as of 2020
Positive impact of ACA
- Basic Statistic Number of studies that find positive effects of Medicaid expansion as of 2021
Number of studies that find positive effects of Medicaid expansion as of 2021
Number of studies on the effects of ACA Medicaid expansion on select outcomes in the U.S. published between Jan. 2014 and Mar. 2021, by study finding
- Basic Statistic Number of ACA-related enrollments in the U.S. 2014-2024
Number of ACA-related enrollments in the U.S. 2014-2024
Number of Affordable Care Act-related (ACA) enrollments in the Marketplace, Medicaid, and the Basic Health Program (BHP) in the U.S. from 2014 to 2024
- Basic Statistic Impact of Medicaid expansion on mortality in the U.S. 2014-2017
Impact of Medicaid expansion on mortality in the U.S. 2014-2017
Cumulative impact of Medicaid expansion on mortality among older adults in the U.S. from 2014 to 2017
- Basic Statistic Impact of Medicaid expansion on mortality in the U.S. 2014-2017, by state
Impact of Medicaid expansion on mortality in the U.S. 2014-2017, by state
Cumulative impact of Medicaid expansion on mortality among older adults in the U.S. from 2014 to 2017, by state
- Basic Statistic Traditional Medicaid savings from Medicaid expansion in select U.S. states as of 2020
Traditional Medicaid savings from Medicaid expansion in select U.S. states as of 2020
Estimated savings to traditional Medicaid from Medicaid expansion for select U.S. states and years, as of 2020
Payment & delivery reform: Accountable Care Organizations
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- Premium Statistic Number of ACOs in Medicare Shared Savings Program 2012-2023
- Premium Statistic Number of beneficiaries assigned to ACOs in Medicare Shared Savings Program 2012-2023
- Basic Statistic Number of ACO participants in Medicare Shared Savings Program 2023
- Premium Statistic Earned savings of ACOs in Medicare Shared Savings Program 2012-2021
- Premium Statistic Gross federal savings from ACOs in Medicare Shared Savings Program 2013-2023
- Basic Statistic Overall quality scores of ACOs in Medicare Shared Savings Program 2012-2021
Payment & delivery reform: Accountable Care Organizations
- Premium Statistic Number of ACOs in Medicare Shared Savings Program 2012-2023
Number of ACOs in Medicare Shared Savings Program 2012-2023
Number of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program in the United States from 2012/2013 to 2023
- Premium Statistic Number of beneficiaries assigned to ACOs in Medicare Shared Savings Program 2012-2023
Number of beneficiaries assigned to ACOs in Medicare Shared Savings Program 2012-2023
Number of beneficiaries assigned to Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program in the United States from 2012/2013 to 2023 (in millions)
- Basic Statistic Number of ACO participants in Medicare Shared Savings Program 2023
Number of ACO participants in Medicare Shared Savings Program 2023
Number of Accountable Care Organization (ACO) participants in the Medicare Shared Savings Program (MSSP) in the U.S. as of January 2023
- Premium Statistic Earned savings of ACOs in Medicare Shared Savings Program 2012-2021
Earned savings of ACOs in Medicare Shared Savings Program 2012-2021
Total earned shared savings of Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) in the U.S. from 2012 to 2021 (in million U.S. dollars)
- Premium Statistic Gross federal savings from ACOs in Medicare Shared Savings Program 2013-2023
Gross federal savings from ACOs in Medicare Shared Savings Program 2013-2023
Gross federal savings from Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) in the U.S. from 2013 to 2023 (in million U.S. dollars)
- Basic Statistic Overall quality scores of ACOs in Medicare Shared Savings Program 2012-2021
Overall quality scores of ACOs in Medicare Shared Savings Program 2012-2021
Average overall quality score of Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) in the U.S. from 2012 to 2021
Payment & delivery reform: HRRP & HACRP
4
- Basic Statistic Number of U.S. hospitals Medicare punished for high readmissions in FY 2023
- Basic Statistic Number of U.S. hospitals Medicare punished for high readmissions FY2022, by years
- Basic Statistic Number of U.S. hospitals Medicare punished for high readmissions FY 2015-2023
- Basic Statistic U.S. hospitals Medicare punished for high hospital-acquired conditions FY 2015-2022
Payment & delivery reform: HRRP & HACRP
- Basic Statistic Number of U.S. hospitals Medicare punished for high readmissions in FY 2023
Number of U.S. hospitals Medicare punished for high readmissions in FY 2023
Number of hospitals in the United States that Medicare punished in FY 2023 for high readmission
- Basic Statistic Number of U.S. hospitals Medicare punished for high readmissions FY2022, by years
Number of U.S. hospitals Medicare punished for high readmissions FY2022, by years
Number of acute-care hospitals in the United States that Medicare punished for high readmission as of FY2022, by the number of years punished
- Basic Statistic Number of U.S. hospitals Medicare punished for high readmissions FY 2015-2023
Number of U.S. hospitals Medicare punished for high readmissions FY 2015-2023
Number of hospitals in the United States that Medicare punished for high readmission from FY2015 to FY2023
- Basic Statistic U.S. hospitals Medicare punished for high hospital-acquired conditions FY 2015-2022
U.S. hospitals Medicare punished for high hospital-acquired conditions FY 2015-2022
Number of hospitals in the United States that Medicare punished for high rates of hospital-acquired conditions (HAC) from FY2015 to FY2022
Public opinion
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- Basic Statistic U.S. opinion on the ACA April 2010-March 2023
- Premium Statistic Share of U.S. adults who approved or disapproved of ACA in 2020, by party
- Basic Statistic U.S. public opinion: overturning ACA/Obamacare 2020, by party
- Basic Statistic U.S. public opinion: overturning ACA's pre-existing condition protection 2020
- Basic Statistic Public opinion on intentions of health care plans U.S. January 2020
Public opinion
- Basic Statistic U.S. opinion on the ACA April 2010-March 2023
U.S. opinion on the ACA April 2010-March 2023
Percentage of public with favorable or unfavorable opinion of the Affordable Care Act (ACA) from April 2010 to March 2023
- Premium Statistic Share of U.S. adults who approved or disapproved of ACA in 2020, by party
Share of U.S. adults who approved or disapproved of ACA in 2020, by party
Percentage of U.S. adults who approved or disapproved of the Affordable Care Act (ACA) and said whether changes were needed in 2020, by party identification
- Basic Statistic U.S. public opinion: overturning ACA/Obamacare 2020, by party
U.S. public opinion: overturning ACA/Obamacare 2020, by party
Public support and opposition for overturning the Affordable Care Act (ACA/Obamacare) in the U.S. in 2020, by party affiliation
- Basic Statistic U.S. public opinion: overturning ACA's pre-existing condition protection 2020
U.S. public opinion: overturning ACA's pre-existing condition protection 2020
Public support and opposition for overturning the Affordable Care Act's (ACA's) protections for people with pre-existing conditions in the U.S. in 2020, by party affiliation
- Basic Statistic Public opinion on intentions of health care plans U.S. January 2020
Public opinion on intentions of health care plans U.S. January 2020
Opinion on cost and coverage goals of Medicare-for-all, public option, and the Affordable Care Act as of January 2020
