Affordable Care Act Anniversary: There’s Still More Work To Do

What year was it?

  • The number of non-elderly uninsured Americans was 48.2 million (18.2%)
  • Uninsured children under the age of 18 was 9.8%
  • Employer-sponsored insurance covered 55.3% of the population
  • 5% of the population was covered by Medicare
  • 9% of the population was covered by Medicaid with some individuals covered by Medicare and Medicaid

Medicaid for childless adults was not an option in most states, and the insurance Marketplace was not yet created. Children aged out of their parent’s commercial insurance as young as 19, although many states had laws increasing the age to 23. Pre-existing conditions priced many Americans out of the insurance market and policy maximums caused loss of coverage.

The year was 2010!

On March 23, 2010, the Affordable Care Act was signed into law. Ten years later, in early 2020, the number of non-elderly uninsured Americans was 30 million and the percentage had shrunk to 11.1.

The number of non-elderly uninsured Americans reached its low point of 28.2 million (10.4%) in 2016. This was two years after states began expanding Medicaid coverage to adults under 138% of the Federal Poverty Level. Today, 37 states have implemented Medicaid expansion, Missouri and Oklahoma are implementing on July 1, 2021, and 12 states have not expanded.



The year 2020 was “unprecedented” in many ways. As we look in the rearview mirror, we can see the impact of the 2010 Affordable Care Act.

Medicaid is countercyclical. When the economy sees a downturn, Medicaid enrollment and spending typically go up. Medicaid acts as a safety net and Medicaid expansion, under the Affordable Care Act, widened the net.

The Marketplace was available for individuals with income over 100% of the Federal Poverty Level who qualified for a Special Enrollment Period. President Biden recently reopened the Federal Marketplace for enrollment between February 15 and August 15, 2021. Most of the 13 State-Based Marketplaces followed suit.

Pre-existing conditions are no longer a barrier to enrollment, and policy maximums are a thing of the past. Children can remain on their parent’s commercial insurance until age 26, regardless of marital status.


More work to do

Estimates from the Congressional Budget Office show an increase in the uninsured from 2019 to 2020 of between .5 and 1.5 million individuals. It could have been worse, considering the unemployment peaked at 14.8% in April 2020, a level not seen since data collection began in 1948. In December 2020, unemployment was improved but still at an elevated 6.7%. The majority of the unemployed, approximately 55%, were in low paying jobs and potentially eligible for Medicaid if they lived in an expansion state.

Combined, the four non-expansion states listed below were home to more than one-third of the nation’s non-elderly uninsured as of 2019.

  • Texas – 5.4 million
  • Florida – 2.9 million
  • Georgia – more than 1 million
  • North Carolina – more than 1 million

The Affordable Care Act provides for a 90% Federal Medical Assistance Percentage (FMAP) matching-rate for state expansion of Medicaid to adults aged 19-64 whose income is less than 138% of the Federal Poverty Level with no limitation on assets. The 2021 American Rescue Plan Act further incentivizes state Medicaid expansion by offering a 5% FMAP increase to a state’s base-rate for their non-expansion (general Medicaid) populations. It is estimated that this apples to 79% of a state’s Medicaid programs and will more than offset a state’s expenditures for the 8 quarters it is legislated for.

On March 22, 2021, the eve of the 11th anniversary of the Affordable Care Act, U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra released the following statement:

“In the eleven years since it became law, the Affordable Care Act has saved lives, brought down health care costs, and expanded Medicaid to our most vulnerable neighbors. The lifesaving law has been a game changer, protecting roughly 133 million people with pre-existing conditions and extending quality, affordable health care to millions more. While health care is more in reach today, we have more work to do.”


Enrollment assistance is vital

History and research show that increasing coverage options and affordability is not enough. The real key is enrollment assistance. A survey of uninsured adults conducted by the Urban Institute in September 2020 exemplifies this. Results showed that 46% of respondents knew little to nothing about the Marketplaces and even more were unaware of financial assistance that might be available to help them pay for coverage.

Centauri Health Solutions has been helping the uninsured and underinsured obtain medical coverage since 1984. Hospitals, health systems, Medicare Advantage plans and Medicaid Managed Care plans rely on us to educate and assist their patients and members about coverage options and throughout the application process. How can we help you?




Shanna Hanson, FHFMA, ACB
Manager, Business Knowledge
Centauri Health Solutions, Inc.