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Five Things About the Affordable Care Act Post Open Enrollment

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This post was co-authored by Michael Templeman, Director, New Initiatives at the O’Neill Institute for National and Global Health Law.

Irfan Khan / Los Angeles Times

Irfan Khan / Los Angeles Times

The first open enrollment period for the Affordable Care Act (ACA), or “Obamacare” officially closed on March 31.  Here are five things to know about the ACA post-open enrollment.

1. Number of Enrollees Has Exceeded All Expectations . . . but Debate Rages On.  In spite of the technical glitches, political grandstanding, and generally embarrassing initial rollout of the ACA, the number of initial enrollees has exceeded all expectations.  On Tuesday, the White House announced that 7.1 million previously uninsured Americans have enrolled in private health coverage under the ACA, beating the Congressional Budget Office’s February estimate of 6 million enrollees.  The numbers are comprised of those who enrolled through the federal insurance marketplace ( and state-run exchanges. 

The numbers do not include those previously uninsured who purchased plans directly from insurance companies (~9 million), are newly covered by state expansions of Medicaid (~4.5 million), or are young adults covered through their parents’ insurance plans (~3 million).

Unsurprisingly, there is contentious debate over what these enrollment numbers mean.  The law’s detractors argue that the numbers are inflated and an inaccurate reflection of those individuals that will actually follow through and pay their premiums.  There are also those that note that the numbers include those that had to switch plans because of being made obsolete by the ACA.  And, there are still those that say that the demographic mix of enrollees in the various insurance plans is likely to drive overall premium costs up, not down, which is one of the primary goals of the law.  

2. Legal Challenges Remain.  The ACA must overcome pending legal challenges.  The first is the Hobby Lobby case, which was heard by the Supreme Court on March 25.  The issue in question is whether for-profit corporations may refuse, under religious grounds, to include contraception coverage in the basic health plan, which the Department of Health and Human Services has mandated as part of the ACA.  It is unclear how the Court will rule, but it will likely be a close decision, potentially coming down on gender lines, rather than political ones.

3. States Continue to Refuse to Expand Medicaid.  The 2012 decision by the Supreme Court, while upholding the constitutionality of the ACA, severely limited the law’s proposed framework for Medicaid expansion by the states.  States essentially have full discretion about whether to expand their Medicaid programs.  To date, twenty-six states and the District of Columbia have opted to expand their Medicaid programs, while twenty-four have not.  Those that have not – for example, Florida, Louisiana, Texas, and Virginia – include significant numbers of low-income residents that would greatly benefit from health insurance coverage.

4. Full Implementation of the Employer Mandate Continues to be Pushed Back.  The White House has delayed when the mandate to purchase insurance will go into effect for small and medium employers.  Initially planned to be enforced in 2014, employers with 50 to 99 workers now have until 2016.  This two-year delay is intended as a “phase-in” period.  As the employer mandate covers approximately 72% of all Americans, until it is fully implemented, there will be an incomplete picture of how well the ACA functions in practice.

5. The ACA is Here to Stay.  Finally, despite all of the foregoing, the enrollment numbers represent a significant policy victory, not just for the Democrats, but also for the majority of Americans.  Despite incessant Republican calls to “repeal and replace” the law, opinion polls throughout the enrollment period have consistently indicated that the public would rather keep, but fix, the ACA.  These numbers coupled with the visual images of lines of people waiting to sign up for health insurance these past several days is a powerful validation of that sentiment and is a promising indication that the ACA is here to stay.

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The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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