Although it's not getting much attention lately, even from presidential candidates, the Affordable Care Act (ACA) had a big year in 2015. Foremost, the U.S. Supreme Court ruled on King v. Burwell, in which opponents of the law challenged the federal government's ability to provide subsidies to middle-income individuals to purchase health insurance. The plaintiffs argued that only in states that established their own insurance marketplaces could subsidies be provided. In a 5-4 decision that essentially decided the fate of the law, the court found in favor of the government and for the second time reaffirmed the underpinnings of the ACA.
The Bottom Line
This was a truly landmark decision with sweeping implications that will be felt for decades. At its essence, it cemented the ACA as the law of the land.
With the ACA again saved, it is reasonable to take stock of how it is doing. On the plus side, the greatest achievement of the law has been the increase in the number of those now having health insurance -- approximately nine million added over the past year. This is less than hoped for, but it is movement in the right direction. In addition, there are data supporting positive health outcomes from the law, including an increase in detection of cervical cancer.
However, there are clearly problems. Many states, especially Southern "red" states, refuse to expand Medicaid and extend health care to their poorer citizens. In addition, insurance premiums have risen substantially for many, and others now have to face high deductibles when trying to use their insurance. Despite this, insurance companies claim they are losing money in the ACA exchanges and are pulling out or threatening to do so. Federal funds dedicated to cover insurance company shortfalls have been attacked strategically by Florida senator and presidential candidate Mark Rubio.
Many HIV-infected patients enjoy the benefits of the ACA, such as coverage on their parents' policies for those 26 years and younger, coverage of preventative screening tests such as colonoscopies and PAP smears, and protection from pre-existing condition clauses. Like others, they have also suffered from its flaws, such as some HIV medications being placed on the highest cost-sharing tiers and prior authorizations obstructing their use. Some have seen their out-of-pocket insurance costs climb.
The ACA is imperfect and needs to be tweaked. At the same time, many of us who provide care think it needs to be defended. It is hoped that more states will eventually expand Medicaid -- some are planning to do so. Meanwhile, whether you are an ACA fan or foe, it is a reality that we and our patients may dearly miss it were it not to exist.
What are some other top clinical developments of 2015? Read more of Dr. Wohl's picks.
David Alain Wohl, M.D., is an associate professor of medicine in the Division of Infectious Diseases at the University of North Carolina and site leader of the University of North Carolina AIDS Clinical Trials Unit at Chapel Hill.