Peer Reviewed Policy

What You Should Know About the ACA and the History of Health Insurance in the US

Everything you should know about health insurance history and the ACA


How would repealing the ACA affect your state?

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Spending cut and coverage loss numbers are from Blumberg, Buettgens, and Holahan, in Implications of Partial Repeal of the ACA through Reconciliation, Urban Institute, 2016. The job loss analysis is from Josh Bivens, Repealing the Affordable Health Care Act would cost jobs in every state, Economic Policy Institute, 2017.

“At present, the United States has the unenviable distinction of being the only great industrial nation without compulsory health insurance,” the Yale economist Irving Fisher said in a speech in December----December of 1916 that is.”

Our journey began in 1912.  Apparently, we’re bad at this whole health policy business. In the beginning, Southern politicians decried the involvement of the government in healthcare. Industrial workers in America faced the “problem of sickness,” missing work because of illness, no doubt related to toxic chemical exposures and unsafe work environments.

Image for postChemist and Druggist 6 January 1923.
Image for postChemist and Druggist supplement: 6 January 1923

How could industry keep loyal a politician in-office without meeting the public’s healthcare demands?

Change the demand. The easiest solution: Convince the public, they don’t want universally accessible healthcare. Campaigns warned about “socialized medicine, rationing of family doctors and of freedoms Americans held so dear.”

Image for post“Still Just as Hard to Swallow” is a cartoon included in a pamphlet created by the National Physicians’ Committee titled Showdown on Political Medicine, ca. 1946.

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Americans Spend More Than Any Other Wealth Country

At present, Americans pay more for the same level of care or worse

  • 87% more than Canada

  • 102% more than France

  • 182% more than Japan (which has one of the highest life expectancies)


With a huge new pool of government-subsidized customers, insurers no longer had a financial incentive for trying to cherry-pick only the young and the healthy for coverage. And the mandate would prevent people from gaming the system by waiting until they got sick to purchase insurance.


Touting the plan to reporters, Romney called the individual mandate “the ultimate conservative idea,” because it promoted personal responsibility,” says the Annals of the Presidency, November 2, 2020

Indeed, there were other policies and the relatively small population in MA likely contributed to some lackluster fiscal reward. Large populations are essential for making the policy work. People who stay healthy longer, generate GDP and cost the government much less. They catch cancer early and live. Insured people may have more money to invest in their children, thus paying out in future generations. The scenario in the early 1900s also suggested that it could help with poverty, but that was still a theory.

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The U.S. Has the Lowest Life Expectancy among these countries. Among all countries, it ranks 46th.

Barrack Obama, the ambitious young President who began his term in 2008, saw that starting from scratch would be too disruptive to the economy. It also seemed likely to grate on conservatives. Instead, he proposed something similar to RomneyCare. Getting something passed was more important to Obama than a perfect plan.

He was a son troubled by the early death of his mother, who may have lived had she had access to care earlier. The ACA wouldn’t bring her back, but he reasoned that it might save someone’s mother or father or sister or brother. We would have less suffering, less death, and likely spend less, while finally giving Americans that which our peers have had for a century.

One of the early objections claimed that rationing and “death panels” would surely result, though no one provided evidence for the claim. The concern also failed to recognize the 45,000+ Americans sentenced to death each year from preventable diseases we can easily treat.


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A similar story played out as it had in the 1950s and 60s. The senate minority leaders sought a well-known political strategist named Frank Luntz to help convince the public to oppose the policy. Luntz studied which words could turn public opinion.

Just as they had in the 1950s and 60s Americans responded with strong, albeit irrational fear, toward a “government takeover of medicine.” Luntz work found the message that affected the public the most was this:

“No Washington bureaucrat or healthcare lobbyist should stand between your family and your doctor. The Democrats want to put Washington politicians in charge of YOUR healthcare. We can and must do better. Say no to a Washington takeover of healthcare and say yes to personalized patient-centered care.

The best anti-Democrat message.”

In reality, the act only expanded care, particularly to the poorest Americans. These were people already sentenced to death under the current policy. The policy included nothing approaching “government takeover,” but that message along with the “death panel” schtick seriously weakened the public support. Earlier conciliatory negotiations with the pharmaceutical industry meant that Obama had neutralized that threat. He agreed to leave out the ability to bring in prescriptions from Canada, in exchange for no opposition.

Finally, the votes needed for the ACA came through and the act narrowly passed on November 7, 2009, by a vote of 220–215.


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Some expansion or public option is wildly popular with the public but continues to be ignored by politicians

Since 2017, Congress has spent a great deal of time attempting to repeal the act, but looking at its impact, it’s unclear what upright motivation could exist. The program cost 25% less than projected and states found an economic benefit in multiple sectors not unlike what we sometimes see in developing countries that gain care access.

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Other surprises appeared: poverty rates fell significantly in expanded areas, food security improved, and people defaulted on fewer loans. The whole-of-society benefit that ACA proponents hoped for, began to appear.

Shortly after the election of President Trump, the House attempted to pass the American Health Care Act. The bill’s main impact was that it removed protections for pre-existing conditions: 

“Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.”

Only by the vote of late Senator John McCain did Congress fail to repeal it. That act had a profound impact on the lives of Americans who would not go without care, and without something to put in its place, it seems obvious why McCain opposed.

Senator McCain delivers a surprise no to repeat ACA.

Now, again the ACA hangs in the balance. There is no Senator McCain, only the Supreme Court with its freshly minted judge. Though the Republicans claimed they had no intention of removing protections for pre-existing conditions, that conflicts with their repeated efforts to do so in the past four years.

An estimated 54 million people have a pre-existing condition that could have resulted in them being denied coverage in the pre-ACA individual market. That falls on top of the 14.6 million that lost coverage by June 2020. That’s a population much larger than many countries.

In the last four years, drug prices have stayed the same or risen despite promises to lower prices, meaning the uninsured would have little hope of a greater ability to afford healthcare expenses. AP analyzed 4,412 brand-name drug price increases and 46 price cuts for the 2018 year. For increases to decreases, it was a staggering ratio of 96 increases per 1 decrease.

To date, no one has put forth a viable healthcare policy to put in the ACA’s place, despite actively trying to remove it. Like many Americans, I’ll be crossing my fingers. Opening arguments began on November 10, 2020.