Access to Care and the Affordable Care Act: Why Do Problems Exist 15 Years Later?

This editorial is the first in a series of 4 discussions about the affordability of health care. The topics will include an evaluation of drug prices, prior authorizations required by health care insurers, and governmental health care programs.

The affordability of health care will be the top issue in the upcoming midterm elections. However, the discussion about health care affordability began more than 15 years ago with the passage of the Affordable Care Act (ACA), which was dubbed Obamacare. Under the ACA, every American was to have health insurance and access to care. Citing PolitiFact, Mark Memmott of National Public Radio in December 2013 reported that President Barack Obama told the “lie of the year,” publicly claiming more than 35 times that “if you like your health care plan, you can keep it.”^1,2 The ACA was also supposed to allow patients to “keep their doctor” and save each family of 4 about $2500 per year, which never occurred.³

Although signed into law in 2010, the ACA went into full effect in 2014, as there was an early debacle with the creation of its website, among other administrative and judicial delays. As the provisions of the ACA became widely available, thenumber of uninsured Americans declined to 35.7 million (10%) in 2014 even though cost remained a barrier for 48% of the uninsured.⁴This was a significant decline from the 48.2 million (14%) in 2010 during the highest rate of unemployment after the Great Recession (2007-2009) with its albeit slow economic recovery.⁵In 2020, during the COVID-19 pandemic, the number of uninsured people continued to decline to 31.6 million (9.7%) with the significant infusion of government subsidies. With continued governmental subsidies, the uninsured total further declined to 27.6 million (8.4%) in 2022 (Figure). This decline in the uninsured rate was largely accomplished through continued government subsidies and an almost 50% expansion of Medicaid coverage.In 2023 despite the recent Covid experience, 25 million Americans representing 7.6% of the total population, were still uninsured.As the Covid risk became more distant, the uninsured rate increased to 8.2%, or 27.2 million Americans in 2024.^6,7

Rather than the ACA providing universal health care insurance as initially intended, this high number of uninsured Americans persists despite the continuation of the ACA Covid-19–era government subsidies and Medicaid expansion. Among working-age Americans—aged 18 to 64 years—11.6% did not have health insurance in 2024, which was a nonsignificant decrease from 13.9% in 2020 during the pandemic.In 2024, while almost two-thirds (65.4%) of people younger than 65 years had private health insurance, 26.6% were covered by public health insurance. Despite multiple federal programs, approximately 5% of America’s children (aged 0 to 17 years) consistently remain uninsured since the passage of the ACA.⁷ 

As a surrogate to dynamic census data, the overall birth rate in the US has declined, while the total population receiving health insurance benefits has increased. During this time, the birth rate in the US declined from a birth to death ratio of 1.62 in 2010 to 1.52 in 2014, then to 1.07 in 2020, and increased to 1.16 in 2023 (Table).⁸ The Hispanic population in the US, however, is the only group with increasing birth rates, with birth to death ratios equaling 6.54, 5.4, 2.84, and 3.65, respectively. Even though the US population officially totaled 338.4 million in 2023, the population in the US with health insurance increased from 342.9 million in 2010, 355.8 million in 2014, and 376.3 million in 2020, to 396.3 million in 2023.⁹ However, almost 1 in 4 Hispanic adults aged 18 to 64 years (24.8%) lacked health insurance.^6,7 By 2024, it was clear that immigrants were accessing state-run Medicaid, CHIP and other government programs even though ineligible under federal statutes.¹⁰ The number of uninsured Americans also may be grossly inaccurate if ineligible individuals are accessing Medicaid and CHIP.Rapidly adding more than 10% to the US population significantly stressed the already overburdened health care and Medicaid systems.

Poverty was among the most prominent driving factors for the recent influx of migrants to the US, which brings significant public health and economic implications, ranging from infectious diseases, such as human papillomavirus (HPV), to oncology. From the public health perspective, the incidence and mortality rates from cancer in Latin America and the Caribbean nations (LAC) are among the highest in the world, comprising about 8.4% of the global population. The significant cancer burden in LAC is due to high rates of poverty, resulting in wide disparities in access to health care.¹¹ Despite HPV vaccination initiatives in LAC, cervical cancer remains a leading cause of cancer death in 6 countries and the second leading cause of death in 14 others.¹² The expansion of Medicaid under the ACA for impoverished US citizens and migrants has severely strained the fragile American health care system. Before the population influx between 2021 and 2025, there was already a shortage of oncology providers. Using cervical cancer as an example, in 2019, there were 1527 gynecologic oncologists registered with a national provider identifier in the US. However, 61.8% of US counties lacked a gynecologic oncologist in their local or adjacent county, and no gynecologic oncologist was nearby in 37.2% of counties with the highest gynecologic cancer rates.¹³ Based on the first principle of economics, with finite health care infrastructure and funding, greater demand for services predictably results in higher costs for health care.

The ACA has not achieved its promise of universal health care insurance. Most importantly, the ACA’s decline in the number of uninsured people was accomplished through Medicaid expansion and government subsidies. At the time of this writing, the federal government was previously and is once again partially shut down, in part, to maintain COVID-19–era government subsidies for ACA plans.¹⁴ Without these subsidies, the average cost of ACA health care insurance would increase an average of $1500 per year, which is currently borne by US taxpayers.

Especially with the recent rapid increase in the US population and expanded access to Medicaid, the ACA is anything but “affordable.” The cost of health care continues to be a significant factor in the US affordability crisis and remains a millstone for Congress and the taxpayers it represents.

References

1. Memmott M. Obama’s “you can keep it” promise is “lie of the year.” National Public Radio. December 13, 2013. Accessed February 24, 2026. https://tinyurl.com/46663wz9

2. Obama: “if you like your health care plan, you’ll be able to keep your health care plan.” PolitiFact. Accessed February 24, 2026. https://tinyurl.com/2vxtw5zc

3. RNC ad blames Obama for $1,300 spike in family health care premiums. News release. PolitiFact. March 20, 2012. Accessed March 24, 2026. https://tinyurl.com/5sjjfnx9

4. Key Facts about the uninsured population.The Henry J. Kaiser Family Foundation. October 2015. Accessed March 24, 2026. https://tinyurl.com/53mnp97f

5. Finegold K, Conmy A, Chu RC, Bosworth A, Sommers BD.Trends in the U.S. uninsured population, 2010-2020.ASPE Office of Health Policy. February 11, 2021. Accessed March 24, 2026. https://tinyurl.com/534f92ak

6. Cohen RA, Briones EM, Sohi I. Health insurance coverage: early release of estimates from the National Health Interview Survey, 2024. National Center for Health Statistics. Released June 2025. Accessed February 25, 2026. https://tinyurl.com/2aub4tyk

7. National health expenditure data. CMS. Updated September 22, 2025. Accessed March 2, 2026. https://tinyurl.com/dtcxke5p

8. Driscoll AK, Hamilton BE, Tejada-Vera B, Minino AM. Natality and mortality trends in the United States, 2000–2024. National Center for Health Statistics. Updated February 4, 2026. Accessed February 25, 2026. doi:10.15620/cdc/20250305001

9. US and world population clock. United States Census Bureau. Accessed February 26, 2026. https://tinyurl.com/3s724ved

10. Heisler EJ, Kilker AF. Noncitizens’ access to health care. Congressional Research Service. November 14, 2024. Accessed March 24, 2026. https://tinyurl.com/4d6u39xz

11. Leite LF, da Conceição LD, Saldanha EF, et al. Cancer incidence and mortality estimates in Latin America and the Caribbean: a systematic analysis of the GLOBOCAN 2022. Cancer Res Commun. 2025;5(12):2236-2248. doi:10.1158/2767-9764.CRC-25-0564

12. Pan American Health Organization. Evaluating the impact of the human papillomavirus vaccine in Latin America and the Caribbean. October 31, 2023. Accessed February 25, 2026. https://tinyurl.com/5xc926nf

13. Ackroyd SA, Shih YC, Kim B, Lee NK, Halpern MT. A look at the gynecologic oncologist workforce—are we meeting patient demand? Gynecol Oncol. 2021;163(2):229-236. doi:10.1016/j.ygyno.2021.08.013

14. Simmons-Duffin S. What’s behind the health care fight that led to the government shutdown. North Country Public Radio. October 2, 2025. Accessed February 26, 2026. https://tinyurl.com/2frsyufm