The Affordable Care Act: 10 Things to Know

The Affordable Care Act (ACA), signed into law in 2010, transformed healthcare in the United States. Most of the major provisions are still in effect as of 2025, although some parts of the law have evolved, and certain features have been replaced or phased out. Here are ten things to know about the health reform law.

1. The Affordable Care Act: By the Numbers

• $938 billion - Cost originally projected to implement the provisions of the healthcare law over the first decade, according to figures from the Congressional Budget Office (CBO). However, total federal Affordable Care Act expenditures have far exceeded this original estimate, especially after pandemic-era enhancements and expansions. Today, they stand at around $1.5 trillion since implementation. (Recent legislative changes will reduce the federal costs but potentially cause millions of Americans to lose coverage.)
• 219 to 212 - Final tally of the razor-close House vote to pass the healthcare bill on March 21, 2010.
• 2,300 - Number of pages (approximate) in the text of the full bill.

2. The Law Used to Require You to Have Health Coverage or Pay a Penalty

As originally written, the law required all citizens and legal residents in the United States to have at least basic health insurance coverage, and those without coverage were subject to a phased-in tax penalty that was scheduled to rise every year a person wasn't covered. However, as of 2019, while the law itself hasn't changed, there is no federal penalty for noncompliance.

3. If You're Insured, The Law Doesn't Change Your Coverage

If you're insured through an employer's plan, for example, you may keep the coverage you have. You aren't required to get coverage through the government.

4. You Can Get Health Coverage If You Need It

U.S. citizens and legal residents can buy health insurance through a system of exchanges run by state government agencies or nonprofits (these exchange programs are officially called "American Health Benefit Exchanges"). To help people afford purchasing individual health coverage, a premium assistance credit is provided for those who purchase health insurance from a state exchange and aren't eligible for other affordable coverage. The purpose of the credits is to ensure that people don't have to spend more than a specified percentage of their household income on health insurance.

Originally, the premium tax credit was only for low- and moderate-income individuals with a household income between 100% and 400% of the federal poverty level. But Congress removed the 400% limit for 2021 through 2025. During these years, if you earn over 400% of the federal poverty level, you're required to pay no more than 8.5% of your household income for Affordable Care Act health insurance.

5. Employers Required to Offer Coverage or Pay a Fine

Employers that have 50 or more full-time employees are required to offer health insurance to their employees or pay a federal penalty. This provision remains applicable today, although some transition rules have ended.

6. Patients With Preexisting Medical Conditions Get Special Protections

The healthcare law gives specific protections to children and adults who are in danger of being denied health insurance coverage because of a preexisting medical condition, which can include anything from asthma to diabetes and heart disease. Under the rules, no one with a preexisting medical condition can be denied health insurance coverage.

7. Medicaid Coverage Was Expanded

Adults without children became entitled to Medicaid coverage for the first time in the program's history. However, some states have still not expanded Medicaid.

In 40 states and the District of Columbia, adults can get Medicaid if their income is up to 138% of the federal poverty level ($22,977 a year for individuals, or $44,367 for a family of four (2025)). Eligibility is determined by current monthly income, so individuals can qualify even if their annual income is over these levels. As a result of the One Big Beautiful Bill Act, starting in 2027 (2028 for states that request a one-year delay), able-bodied adults aged 19 to 64 will be required to complete 80 hours per month of work, volunteering, or education to stay eligible for Medicaid. The work requirement will not apply to anyone who is disabled, pregnant, or caring for a child younger than age 14. For more information, see www.healthcare.gov/medicaid-chip.

8. Older Children Can Get Covered on Their Parents' Health Plans

Under the healthcare law, parents are able to include their older children on a group health insurance plan until the children are 26 years old. The child doesn't need to be a full-time student or be claimed as a dependent on the parent's income tax return in order to qualify.

9. Healthcare Reform Doesn't Come Cheap

Since implementation, Affordable Care Act costs are around $1.5 trillion. It is paid for in a number of ways, including:

• imposition of fees on health insurers, pharmaceutical companies, and medical device manufacturers
• increases to Medicare taxes for high-income individuals and households, including a tax on income that comes from investments and interest, and
• cuts in payments made to healthcare providers and insurers under Medicare and other health programs.

10. Second Opinions on Healthcare Reform Are Everywhere

Critics of the healthcare law have objections that range from the theoretical to the practical. Some say the federal government has no business legislating about healthcare for individuals. Others worry about the impact of treating all of the patients who enter the healthcare system, with concerns ranging from a potential shortage of primary care physicians to patients having a tougher time finding a doctor (and spending more time in the waiting room once they do).

Visit Healthcare.gov or CMS.gov for current information.