The Affordable Care Act (ACA) was signed into law in March 2010 with the goal of
increasing access to affordable health insurance coverage and improving the overall health of Americans. Here are some of the key changes the ACA has made to the under 65 health insurance landscape:

• Individual Mandate: When the ACA was initially implemented an individual mandate requiring individuals to have health insurance coverage or face a penalty. This was intended to encourage younger and healthier people to participate in the insurance market and balance out the costs of covering older and sicker individuals. The individual mandate still exists, but the federal penalty for non-compliance was eliminated starting in 2019. Some states still impose their own penalties for people who don't maintain minimum essential coverage.
• Health Insurance Marketplaces: The ACA created health insurance “marketplaces” to provide a one-stop shopping experience on a trusted government website for consumers to enroll in federally subsidized health plans that meet a common set of coverage standards. The marketplaces are meant to foster competition on price and value, facilitate meaningful plan comparison, and allow consumers to sign up for affordable, comprehensive private coverage. Some states opted to run their own marketplace while other states have ceded this responsibility to the federal government.
• Medicaid Expansion: The ACA expanded Medicaid eligibility to all individuals with income up to 138% of the federal poverty level. This has resulted in millions of low-income individuals gaining access to health insurance coverage.
• Essential Health Benefits: The ACA requires all health insurance plans sold on the individual and small group markets to cover 10 essential health benefits. This ensures that individuals have access to a minimum level of coverage, listed below:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
• Pre-existing Conditions: The ACA prohibits health insurance companies from denying coverage or charging higher premiums based on pre-existing conditions. This has provided protections for individuals with chronic health conditions who may have previously been denied coverage or faced unaffordable premiums.
• Young Adult Coverage: The ACA requires health insurance plans to allow young adults to stay on their parents' plan until age 26. This has helped millions of young adults maintain health insurance coverage as they transition into the workforce and establish their own careers.
• Medical Loss Ratio: The ACA requires health insurance companies to spend at least 80% of premium dollars on medical care and quality improvement activities, rather than administrative costs and profits. This has helped to ensure that more of individuals' premium dollars are going towards actual medical care.

Overall, the ACA has made significant changes to the under 65 health insurance landscape. While there have been challenges and criticisms, the law has resulted in millions of previously uninsured individuals gaining access to health insurance coverage and has provided important protections for those with pre-existing conditions.