The Supreme Court will review the constitutionality of the Affordable Care Act (ACA) this November in California v. Texas (known as Texas v. U.S. in the lower courts). Late last year, a federal appeals court panel ruled that the ACA’s individual mandate is unconstitutional, since Congress has set the mandate tax penalty to zero. The case was brought by a number of Republican state officials and two individuals, who argue that the rest of the ACA is not severable from the mandate and should therefore be invalidated. The Trump administration now argues that nearly all of the ACA should be found invalid but that the courts should prohibit it from enforcing only the provisions found to harm the individual plaintiffs. It previously argued that only the ACA’s pre-existing condition protections should be overturned. Pending a final decision on the case, the Trump administration has continued to enforce the ACA.

The ACA’s reforms affect nearly every American in some way, and a Supreme Court decision that invalidated the ACA would have complex and far-reaching impacts throughout the health care system. While the ACA’s changes to the individual insurance market – including protections for people with pre-existing conditions and premium subsidies for low and modest income people – have been the focus of much policy debate and media coverage, the law made many other sweeping changes. These include: the expansion of Medicaid eligibility for low-income adults; required coverage of preventive services with no cost-sharing in private insurance, Medicare, and for those enrolled in the Medicaid expansion; new national initiatives to promote public health and quality of care; and a variety of tax increases to finance these changes. The number of uninsured Americans decreased by 20 million from 2010 to 2016 as the ACA went into effect, but has since increased by 2.3 million from 2016 to 2019.

The following table summarizes the major provisions of the ACA, illustrating the breadth of its changes to the health care system, and public attitudes towards those changes. If all or most of the ACA is struck down, many of these provisions could be eliminated.

Due to differences in populations and policies across states, the potential repeal of the ACA would play out differently from state to state. For example, over 50 million people had a declinable health condition in 2018, including over a third of the population in West Virginia, Arkansas and Mississippi. The appendix shows the state-by-state impacts of these key ACA provisions. A link to state-level data is included in the table below when data are available.

Browse Key Provisions by Category:

Expanded Eligibility for Health Coverage

Key Provisions Impact Public Opinion Medicaid Eligibility Expansion Medicaid eligibility is expanded to include adults with income up to 138% FPL; however, the Supreme Court ruling in 2012 essentially made Medicaid expansion optional for states.

The federal government paid 100% of the cost of the expansion initially; this share phased down to 93% in 2019 and 90% in 2020 and beyond In June 2019, there 14.8 million Medicaid expansion enrollees in the 34 states and DC that had adopted the expansion. Of those enrollees, 12 million were newly eligible due to the ACA’s Medicaid expansion [View state level data] 87% say it is “very important” (57%) or “somewhat important” (29%) that the part of the law that gives states the option of expanding their Medicaid programs to cover more low-income, uninsured adults remains in place if the ACA is ruled unconstitutional (July 2019)

66% of those living in non-expansion states would like to see their state expand Medicaid (May 2020) Subsidies for Nongroup Health Insurance Eligible individuals who buy coverage through the Marketplace receive subsidies based on income: premium tax credits for those with income 100-400% FPL; cost-sharing subsidies for those with income 100-250% FPL

States can also elect to run a subsidized Basic Health Plan for people with income between 133%-200% FPL As of February 2020, 9.2 million Marketplace enrollees received premium tax credits and 5.3 million received cost-sharing reductions

In 2020, there are about 0.9 million people enrolled in the Basic Health Plans in Minnesota (83,200) and New York (796,998) [View state level data] 85% say it is “very important” (57%) or “somewhat important” (28%) that the part of the law that provides financial help to low- and moderate-income Americans who buy their own insurance remains in place if the ACA is ruled unconstitutional (July 2019) Dependent Coverage to 26 All non-grandfathered private group and non-group health plans must extend dependent coverage to adult children up to the age of 26 About 2.3 million young adults gained coverage as a result of this provision 78% of the public say it is “very important” (51%) or “somewhat important” (27%) that the part of the law that allows young adults to stay on their parents’ insurance plans until age 26 remains in place if the ACA is ruled unconstitutional (July 2019) Health Insurance Marketplace Establish new marketplaces where qualified health plans are offered to individuals

Marketplaces certify that qualified health plans meet all ACA requirements, provide subsidies to eligible individuals, operate a website to facilitate application and comparison of health plans, provide a no-wrong-door application process for individuals to determine their eligibility for financial assistance, and provide in-person consumer assistance through navigators 10.7 million individuals had effectuated coverage through the Marketplace as of the first quarter of 2020

67% of Marketplace enrollees will have a choice of three or more insurers in 2020

26 insurers are entering state Marketplaces for 2020

Individual market gross profit margins have been higher, on average, in 2017-2019 than before the ACA was implemented [View state level data] 82% of the public (91% of Dems, 78% of Inds, 71% of Reps) have a favorable view of creating health insurance exchanges where people and small businesses can shop for insurance (Nov 2018)

45% say that the health insurance marketplaces are working well in the nation overall, while 47% say they are not working well (November 2019)

52% say that the health insurance marketplaces in their state are working well, while 39% say they are not working well. Those in states with state-run marketplaces are more likely to say they are working well than those in states using healthcare.gov (58% vs. 48%) (November 2019)

Federal Minimum Standards for Private Health Insurance

Other Provisions Affecting Employers/Group Health Plans

Key Provisions Impact Public Opinion Large Employer Mandate Requires employers with at least 50 full time workers to provide health benefits or pay a tax penalty Favored by a majority across parties: 69% overall have a favorable view, including 88% of Dems, 61% of Inds, 56% of Reps (November 2018) Waiting Periods Employers that impose waiting periods on eligibility for health benefits (e.g., for new hires) must limit such periods to no more than 90 days Prior to the ACA, in 2009, 29% of covered workers faced a waiting period of 3 months or more

Consumer Assistance

Key Provisions Impact Public Opinion State Consumer Assistance Programs Authorize federal grants for state Consumer Assistance Programs (CAPs) to advocate for people with private coverage.

Notice of claims denials by non-grandfathered private plans must include information about state CAPs that will help consumers file appeals CAPs were established in most states in 2010, though no appropriations for CAPs have since been enacted. Today 36 CAPs are in operation

A report on the first year of CAP operations found the programs helped 22,814 individuals successfully challenge their health plan decisions and obtained more than $18 million on behalf of consumers

Other Medicaid Provisions