How Healthcare Has Changed Over the Past Quarter Century

With the 2020s underway, let’s take a look back at seven key milestones and issues that marked the evolution of healthcare over the past 25 years.

1. The Affordable Care Act became law

Just months into 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. The Affordable Care Act, often referred to as the ACA or Obamacare, changed the nation’s health insurance landscape and  brought about numerous provisions to help make health insurance more affordable and accessible to as many Americans as possible.

Some key provisions include:

• The creation of a health insurance marketplace in every state to provide consumers with a place to purchase health insurance.
• Income-based subsidies, including premium tax credits and cost-sharing reductions, for those who purchase individual coverage through the health insurance marketplace (i.e., the state-based and federal exchanges).
• A requirement that insurance plans cover young adults on their parents’ policies to age 26.
• Guaranteed issue and renewal of policies.
• Medicaid expansion to those with incomes below 138% of the federal poverty level, in participating states. 
   

Ten years later, uninsured rates have declined. In 2010, nearly 16% of Americans were uninsured. But in 2016, the uninsured rate hovered just above 8% - its lowest point in the decade. Although, it started to increase again slightly in 2017.

2. Short-term health insurance kept its stride

Short-term health insurance is temporary insurance that provides coverage in certain medical situations like an unexpected accident or illness. However, it doesn't include the same essential health benefits that ACA plans do, making it a more affordable insurance option for many.

Short-term health plans remained a relevant health insurance option throughout the decade with sales increasing sharply after the ACA took full effect in 2014. These plans became an attractive option for people who were exempt from the individual mandate or opted to pay a penalty for not having an ACA-compliant health plan.

Obama limits short-term policies

Concerned that short term health insurance was impacting ACA enrollment, the Obama administration created regulations that limited their availability. In 2016, short term health insurance policy durations were capped at three months.

Trump expands short-term policies

In 2018, the Trump administration lifted Obama-era limits. Policies can now last up to 12 months and can be renewed for up to 36 months, depending on state laws. Arizona, for example, has adopted the Trump administration’s regulation. Some states, such as Oregon, still limit short-term plans to less than 90 days.

3. High-deductible health plans grew in popularity

High-deductible health plans, called HDHPs, were introduced in the early 2000s and  were considered "mainstream plans" by 2012. People obtained these plans usually through their employer group-based coverage (if offered), the healthcare exchange, or from private insurers. 
 

Here are some interesting facts:

• HDHP enrollment jumped from 10 million people to 11.4 million people in one year (from January 2010 to January 2011).
• By 2015, HDHPs accounted for 60% to 80% of plans offered in the individual health insurance marketplace. 
• In 2019, the IRS classified high-deductible health plans as any plan with a deductible of at least $1,350 for an individual and $2,700 for a family. The average annual deductible for individual coverage through a group plan was $1,655 in 2019.

But while consumers can appreciate the lower monthly premium of a high-deductible insurance plan, they also tend to delay or skip medical care because of the high out-of-pocket costs associated with HDHPs.

The popularity of HDHP may be slowing - at least in the group market. The percentage of employers offering a high-deductible health plan as the only option is projected to decrease in 2020, with more employers beginning to offer additional coverage options.

4. Healthcare spending continues to climb

If it seems like your healthcare costs increased throughout the past decade, it probably did. In 2018, the average American household spent $5,000 on healthcare, with nearly 70% of the $5,000 going towards health insurance.

The more staggering fact: medical bills are reported to be the number one cause of bankruptcies nationwide. And today, medical costs are considered America’s "real healthcare crisis". And while politicians continue to debate issues including health insurance reform and prescription drug pricing, they have not agreed upon a clear solution.

Until things change, consumers must continue to find ways to save on their own, from finding flexible and affordable health insurance options and taking advantage of preventive care, to comparing provider rates before seeking services and getting alternative healthcare through options like telemedicine.

5. An opioid epidemic devastates our nation

The opioid epidemic might be the most daunting and complex public health crisis of our time. Heroin-related overdoses increased 286% from 2002 to 2013, with a significant spike around 2010. 

Another wave of opioid-related deaths hit around 2013 and this time, synthetic opioids like fentanyl were behind the surge. The crisis continued to escalate from there, with prescription drugs playing a significant role. 

Here are some of the most shocking reports:

• Opioid overdoses accounted for more than 42,000 deaths and increased to 47,600 people in 2017. 
• By 2019, more than 90 Americans per day were dying from opioid overdose. And prescription opioid abuse was costing the nation $78.5 billion per year.
• The epidemic impacted people in both rural and urban environments. But overdose deaths in rural communities surpass deaths in urban settings. 

So what’s being done about it? In early 2019, the Trump administration launched a $353 million initiative to cut opioid overdoses by 40% over the next three years. 

The federal government is also working to hold drug companies accountable. For example, top executives at Insys Therapeutics were found guilty of racketeering conspiracy—a charge typically assigned to drug dealers and mob bosses. 

In 2018, the CDC reported that drug overdose deaths decreased for the first time since 1990.

6. Covid-19 pandemic and the U.S. healthcare system

The 2020 pandemic was not only the biggest health event in the U.S. in the past decade, but a major burden on an already fragile healthcare system. From shortages of hospital beds and staff to healthcare facilities having to ration medical supplies to keep up with COVID-19 cases, we’ve seen how our healthcare infrastructure is in need of improvements to better prepare for crises. 

Not only that, researchers at the Massachusetts Institute of Technology assert that the pandemic revealed some deeper issues in our healthcare system, such as disproportionate access to care among marginalized groups and the country’s dependence on healthcare services from underpaid workers.

7. Medicare enrollment: Medicare Advantage Plans and Original Medicare

Medicare Advantage plans, which are an alternative to Original Medicare, have seen a steady increase in enrollment each year over the past decade. As of 2022, there are 28.4 million Medicare Advantage enrollees which account for 48% of the Medicare-eligible population. People enrolled in MA plans back in 2012 represented about a quarter of all beneficiaries, so enrollment rates have just about doubled.

Another interesting fact as reported by Kaiser Family Foundation is that “the average Medicare beneficiary in 2022 has access to 39 Medicare Advantage plans, the largest number of options available in more than a decade.”

Here’s a breakdown of MA plan enrollment:

• About two-thirds (18.7M) of the Medicare population are enrolled in a plan available through individual enrollment.
• Roughly 5.1 million beneficiaries have coverage through an employer or union group plan available to retirees.
• More than 4.6 million people are enrolled in Special Needs Plans, the majority of which (89%) are those eligible for both Medicare and Medicaid. 

The healthcare debate continues

Discussions about healthcare reform and our healthcare landscape did not stop when the ACA was passed. Conversations about legal challenges continue to this day. There has been proposed legislation to repeal and replace the ACA under the Trump administration. 

Trump administration removes individual mandate

New tax legislation  passed in December 2017, which changed one key aspect of the ACA. Previously, you could be penalized for not having health insurance, but Congress and President Trump eliminated the mandate rule for all coverage beginning Jan. 1, 2019. 

Individual mandate challenged as unconstitutional

The 5th Circuit also ruled in Texas vs. United States that the individual mandate is unconstitutional, at which time, a A Texas Judge was deciding what, if any, of the ACA still stands. But in 2021, the Supreme Court ruled that states don’t have any grounds to challenge the constitutionality of the ACA mandate.

The 2020 election

With the Presidential election in 2020, Democrats were focused on building upon the ACA with tactics like a “Medicare for all” national health insurance system. However, this agenda never took effect with the Democratic party winning the election. 

Now twelve years after the passing of the ACA, the Biden-Harris administration has promised to continue upholding the ACA and making affordable health insurance accessible. With ongoing talks of a universal health insurance option for Americans and how to navigate health-related issues post pandemic, there’s no doubt that healthcare legislation will continue to make headlines over the next decade.  

From Obamacare to the opioid epidemic to the Covid-19 pandemic, healthcare-related issues have made major headlines. And it’s inevitable that they’ll only continue to evolve and impact our lives for years to come. 

We’ll continue to follow the trends and changes as well as their impacts on our nation.