Insurers are booming as ACA debate rages. What does the future hold?

The Affordable Care Act (ACA) is still a very big deal.

That's how President Joe Biden described the landmark legislation on its 14-year anniversary Saturday, surrounded by President Barack Obama, former House speaker Nancy Pelosi and Department of Health and Human Services Secretary Xavier Becerra.

The administration touted positive effects from the ACA, proudly boasting that 21.4 million Americans are enrolled in the program following the recent open enrollment period. More than 5.1 million consumers signed up last period, a 31% increase from the previous year, and they say about 80% of Americans can find a plan for less than $10 a month.

Enrollment in the online marketplace has surged from 8 million in 2014 to more than 20 million in 2024, and 96% of individuals have plan options ranging from at least three different issuers.

Perhaps most importantly, the ACA does not allow insurers to reject coverage due to preexisting conditions.

"Gone are the days when being a woman was considered a pre-existing condition or sick children could be denied health insurance," said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure. "Today, over 100 million Americans have coverage through either Marketplace or Medicaid, thanks in part to increased affordability thanks to the Inflation Reduction Act."

But critics of the ACA are quick to highlight the program's flaws. They saw insurance companies are the overwhelming winners of the legislation.

Since the ACA was enacted in 2010, the collective stock prices of Centene, Cigna, Elevance Health, Humana, Molina Healthcare and UnitedHealth Group rose 1,032% and outpaced S&P 500 ETF, according to the Paragon Health Institute. The institute showed that financial gains mirrored other industries much more closely before the law was passed.

The program is expensive for taxpayers, too.

"The cost to taxpayers has been 36,798 per additional private insurance enrollee and 20,739 per additional non-group enrollee, which is more than triple CBO’s original projections of 10,538 and 6,850, respectively," Paragon said in a report (PDF) in September.

ACA advocates show that more than half of Black, Latino and Asian American enrollees pick silver plans with cost sharing assistance that lower out-of-pocket costs, but Paragon notes that has increased premiums across the board. Instructing insurers to meet the single risk pool requirement has also raised premiums, the authors say.

"While ACA advocates focused on the private market reforms when selling the legislation to the public, the vast majority of individuals who gained coverage following the implementation of the law have done so through Medicaid," the report said.

All told, nearly 3 in 4 Americans polled are dissatisfied with the current healthcare system, data from the Harris Poll show.

Health plans see ACA's promise

In some respects, the ACA appears stronger than ever, with enrollment increasing over time and having rebuked repeal and replace efforts from Republicans in Congress.

Louis DeStefano

"The ACA is here to stay," said Louis DeStefano, senior vice president of growth for Oscar Health, in an interview with Fierce Healthcare.

Still, its existence never quite feels guaranteed. In November, Trump said if he won reelection he'd look for alternatives to the ACA despite the law's popularity. And the preventive services clause, a core provision allowing individuals free access to to preventive services, will likely get appealed to the Supreme Court with its future in serious doubt.

Democrats sounded the alarm that a Trump second term spells danger for the future of ACA, which, despite its flaws, likely doesn't have a good alternative in waiting.

"The Republican health care agenda amounts to nothing more than ripping away care and letting everyone else pick up the pieces," said Sen. Ron Wyden, D-Oregon, in a statement. "Democrats are all in to reject any attempt by Donald Trump and his friends in the Senate to roll back the clock to the days when health care was reserved for the healthy and wealthy and insurance companies were calling all the shots.”

Biden's Inflation Reduction Act extended enhanced federal subsidies created by the American Rescue Plan Act through the end of 2025, potentially providing a level of short-term stability no matter how the election turns out.

"We do expect the ACA to continue to be the model for how healthcare is delivered and it was a successful program even prior to the enhanced subsidies," said DeStefano. "Our goal will still be to remain committed to the member experience."

Blue Cross Blue Shield also said it remains committed to the ACA and working with the White House, Congress and regulators to improve healthcare, a spokesperson said in a statement to Fierce Healthcare. National insurer association AHIP did not return a request for comment.

As part of its long-term strategy, Oscar Health will continue to invest in individual coverage health reimbursement arrangements, or ICHRA. Employers set a defined contribution amount so employees can go out and pick the best plan for them.

He said as more awareness of ICHRA spreads, the benefits behind personalizing healthcare will become more clear for small and large employers. Many large employers right now need to think about diabetes programs, physical therapy solutions and other conditions employees within their company have, effectively becoming a population management organization instead of focusing on core business functions. And, as the ACA grows, competition will lead to a better marketplace for consumers.

"Outside of Oscar, you'll see a Blue Cross, United, Cigna or Aetna in many of the markets," said DeStefano. "That leads an employer to be much more interested to put their employees in a plan. I think that'll help create more of a relationship between the provider, payer and member, where today it's really the employer who really controls who your network and who your payer is going to be," he added.