When Americans come to an agreement on what is just, political stagnation does not hinder action. Currently, health care reform is a primary concern. Prior to the Affordable Care Act (ACA), 60% of individuals depended on employer-sponsored insurance, 20% on government programs, and 20% faced the difficult individual market. The ACA tackled these problems by expanding Medicaid eligibility, eliminating adverse selection, enforcing near-universal participation, and providing subsidies for premiums.
These actions stabilized insurance markets and increased coverage for approximately 20 million Americans by 2016, making outpatient and preventive care more accessible. Although widely supported, the ACA encountered attempts at repeal, especially after 2016, yet prevailed, chiefly because of Senator John McCain’s critical vote. This highlighted the impacts of status quo bias and loss aversion: once benefits are received, Americans work to keep them. This phenomenon has contributed to the durability of programs such as Social Security, Medicare, and ACA subsidies over time.
In 2021, the American Rescue Plan improved ACA subsidies, rendering insurance more economical and reachable. While these subsidies were initially meant to be temporary, they were prolonged, with an expected enrollment of 24 million by 2025. However, the temporary status and the federal expenses involved spark debate, as the subsidies are set to conclude in 2025. Removing them threatens to elevate the uninsured rate and overload emergency departments with unpaid and avoidable care.
Political circumstances indicate that although recent governmental hurdles arose from various factors, the extension of ACA subsidies played a crucial role in hindering Democratic alignment in exceeding the Senate’s 60-vote threshold. Presidents can influence public sentiment and issue executive actions, yet only Congress has the authority to allocate finances.
This underscores the government’s architecture, influenced by political theorists like Rousseau, who argued that legislative power should be entrusted to community-representative lawmakers, and Madison, who cautioned against merging legislative and executive authorities. Thus, the U.S. Constitution assigns law-making to Congress rather than the President, highlighting Congress’s responsibility to citizens through electoral processes and representation.
In spite of the media’s concentration on presidential authority, congressional representatives symbolize the people’s sovereignty, as demonstrated in the discussions surrounding ACA subsidies. Advocacy efforts should concentrate on crucial congressional members, particularly those in pivotal districts and budget-centric positions.
As Congress contemplates the destiny of ACA subsidies, the potential for temporary or extended repeal looms amid partisan divides. Nevertheless, due to historical resistance to repeal and the susceptibility of certain districts, the ACA may survive. Even if subsidies cease, initiatives should target their reinstatement.
Healthcare professionals are vital in this process, relating patient success narratives, lobbying Congress, penning opinion pieces, leveraging social media, collaborating with hospital leadership, and safeguarding access to outpatient care. The evolution of policy is incremental—akin to Social Security in 1935 alleviating poverty for seniors or Medicare in 1965 shielding retirees from exorbitant costs. Sixty years on, the ACA delivers financial and health stability. Despite obstacles, robust public and congressional backing can ensure its longevity as Social Security and Medicare have. With the right objectives, the ACA appears ready for political resilience, propelling the nation toward universal health care access. Now is the moment for action.
Curt Dill is an emergency physician.