Legislative history of the Affordable Care Act (ACA)

February 5, 2023

Legislative history of the Affordable Care Act (ACA)


Healthcare is an important part of any society. Providing affordable healthcare and ensuring that it is not only accessible but also affordable is an important part of any government’s agenda. Thus, the goal is to ensure that, each person has access to affordable health care. Health care in this sense will include the institutions such as hospitals. It will also include providing for insurance to the people so that they can afford health services. In a bid to facilitate for these and other benefits, the state undertakes to enact and legislation to provide for the realisation of affordable and universal healthcare. 

An example of such a step is the Affordable Care Act. This paper seeks to review the legislative history of the ACA. The report shall assess the historical background of the act, its objective and aim and the procedures leading up to its enactment. It shall carry out an overview of essential impacts arising out of it.

History leading up to the ACA

Before the ACA was enacted and came into effect, healthcare and medical insurance was covered in the previous Medicaid enacted back in 1965. The previous health reforms were credible and indeed such as the steps by previous presidents, Theodore Roosevelt, Harry Truman Richard Nixon and Bill Clinton (Cahn, Zachary, and Emily M. Johnston. “Clintoncare and Obamacare: Lessons for Gridlock Theory.” Congress & the Presidency. Vol. 45. No. 3. Routledge, 2018.). These steps however received great opposition and hence were never enacted. The effect of this is that the right to health and its enforcement was left to individual citizens. It was hence one’s private responsibility to seek and provide for the insurance cover. 

It also left did not provide for the realisation of the right tot universal health care. Before ACA the US ranked 43rd in child mortality and 47th in life expectancy. This led to the need for comprehensive reform in the health sector (Banks, Christopher P. “Of White Whales, Obamacare, and the Robert’s Court: The Republican Attempts to Harpoon Obama’s Presidential Legacy.” PS, Political Science & Politics 50.1 (2017): 40.).  The Bush administration made an attempt to push for such reform trough the Patients’ Bill of Rights in 2001. However, this attempt was defeated by Congress making the US one of the most industrialized nations without universal health care.  

Additionally, the state of the healthcare insurance system at the time had detrimental impacts on the patients. This was mainly in terms of health care funding. The ability to pay for health care and get affordable insurance was not only difficult but costly (Ncayiyana, Daniel J. “Obamacare-a stunning legacy.” SAMJ: South African Medical Journal 100 (2010): 259-259.). Coupled with the fact that a large number of the population was uninsured means that the most of the population will not benefit from affordable and accessible healthcare. The situation was even worse for low-income workers who could then not afford private insurance forcing workers to work longer in order to afford the healthcare (Barrilleaux, Charles, and Carlisle Rainey. “The politics of need: Examining governors’ decisions to oppose the “Obamacare” Medicaid expansion.” State Politics & Policy Quarterly 14.4 (2014): 437-460). 

The process in enacting ACA and its key provisions

The processes leading up to the ACA started off with individual legislation in various states that led to more pressure on Congress to come up with federal laws. An example of this was the Insurance expansion bill of 2006 in the state of Massachusetts. The bill provided for provisions requiring an individual mandate and an insurance coverage. The aim of the act was to ensure that everyone to receive healthcare and to allow everyone to be insured.  It is argued that the progressive steps and the great success attributed to the move in Massachusetts led to the Democrats proposing the ACA. Healthcare became an important issue leading up to the 2008 election with both the Republican candidate and the Democratic Party Candidate included the  

Thus, when the Obama administration took the helm in 2008 a key consideration and agenda was the provision of universal healthcare. The government sought to ensure that the citizens who have not been covered under insurance to receive insurance cover (Cannan, John. “A legislative history of the Affordable Care Act: How legislative procedure shapes legislative history.” Law Libr. J. 105 (2013): 131). This proposal would involve the incorporation of individual mandate ensuring virtually every US citizen was insured. Other key proposals made to the Congress was the introduction of income-based subsidies, private and public group insurance. It also had proposals for the expansion of Medicaid with an aim to reduce the number of uninsured people (Metzmeier, Kurt X. “Researching the Patient Protection and Affordable Care Act.” Louisville Bar Association Bar Briefs (2014)).

In 2009, President Obama announced the joint session of Congress of far-reaching healthcare reforms. This led to a succession of health care related bills approved by the House of Representatives. The Senate met numerous times and came up with proposals and principles that led to the ACA (Smith, Peter J. “Federalism, Lochner, and the individual mandate.” BUL Rev. 91 (2011): 1723). The act also received contributions from health policy experts such as Jonathan Gruber and David Cutlter who made proposals on individual mandate. Thus, the act had was well versed with the theme of progressiveness required for such reforms. 

The issue of individual mandate was me by great backlash by Republicans who thought of it as a socialist move (Quadagno, Jill. “Right-wing conspiracy? Socialist plot? The origins of the patient protection and affordable care act.” Journal of Health Politics, Policy and Law 39.1 (2014): 35-56). The proposal was seen by the senator including Mitch McConnell who described the mandate as unconstitutional. This led to the protests and constant debates by various lobbyists and parties such as the 2009 Tea Party Protest. The bill was however assed in the House of Representatives by a 220 to 215 vote and it was subsequently forwarded to the Senate. 

At the Senate where the Committee on Health and Finance. These committees gave proposals and recommendations incorporated in the ACA. After this, the Bill went into the where the Democrats needed the required 60 votes for the bill to be passed (Oleske Jr, James M. “Obamacare, RFRA, and the Perils of Legislative History.” Vand. L. Rev. En Banc 67 (2014): 77). With a sustained amount of negotiation and concessions the Bill was passed to the ACA on a 60-39 vote but not in its comprehensive form. The lack of a comprehensive was decried the by the Democrats who still propose for a conclusive policy (Manchikanti, Laxmaiah, R. M. Benyamin, and J. A. Hirsch. “Evolution of US Health Care Reform.” Pain physician 20.3 (2017): 107-110). The bill later became law in 2010 and was signed into law by President Obama on March 23, 2010.

Impacts of ACA and subsequent developments 

The beneficial impacts of the ACA were undoubtedly the fact that more people could now qualify and get health insurance. The estimated drop in the uninsured people was credited to the Basic Health Program allowing for a total of 11 million people added to Medicaid (Cannan, John. “A legislative history of the Affordable Care Act: How legislative procedure shapes legislative history.” Law Libr. J. 105 (2013) 131). Also, more than 20 million gained insurance cover most of whom were between 18-26.  Moreover, the ACA ensured that even immigrants were also insured and could now have access to healthcare services (McLellan, A. Thomas, and Abigail Mason Woodworth. “The affordable care act and treatment for “substance use disorders:” implications of ending segregated behavioral healthcare.” Journal of substance abuse treatment 46.5 (2014): 541-545). 

There is however a new step to repeal the bill based on a view that it places an unjustified burden on the tax payer. The repeal of the ACA could however act contrary to the advancements made by the loss of the insurance coverage. It would also leave a lot of the young people who were guaranteed by the ACA would lose their cover (Butler, Stuart M. “Repeal and replace Obamacare: what could it mean?.” Jama 317.3 (2017): 244-245). Also, the immigrants and other minorities would lose insurance cover meaning that there will be fewer and fewer insured people (Thompson, Frank J., Michael K. Gusmano, and Shugo Shinohara. “Trump and the Affordable Care Act: Congressional repeal efforts, executive federalism, and program durability.” Publius: The Journal of Federalism 48.3 (2018): 396-424).


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