Obamacare’s 15-Year Toll: A System That Has Become Less Affordable, Less Competitive, and Less Sustainable

In an interview ahead of the official opening of his presidential library, former President Barack Obama was asked to identify his greatest accomplishment. His response centered on the Affordable Care Act (ACA).

“Despite significant resistance from political opponents,” Obama stated, “the ACA has now helped 50 to 60 million people and continues to provide assistance even as current Congress efforts have weakened it and removed critical subsidies for working families.”

However, a closer examination reveals that the U.S. healthcare system is in worse condition than before Obamacare’s implementation across multiple key areas. Cost affordability remains a critical issue. A recent Gallup poll indicates fewer than half of Americans can consistently afford quality care. Obama attributes these challenges to the expiration of enhanced premium subsidies earlier this year—a claim that is misleading, as those subsidies were not part of the ACA but rather temporary pandemic-era measures enacted over a decade after the law’s passage.

In reality, premiums began rising long before such subsidies appeared. According to the U.S. Department of Health and Human Services, average monthly premiums in states using Healthcare.gov more than doubled from $232 in 2013 to $476 by 2017, reaching $619 last year.

The root cause lies in Obamacare’s design: it mandated extensive essential health benefits, restricted insurers’ ability to price plans based on risk, and imposed costly regulations on the individual market. In response, insurers raised premiums. Rather than addressing these systemic issues, Democrats have relied on increasingly generous taxpayer-funded subsidies—including the enhanced subsidies Obama praised—to mask price increases.

The law also introduced significant distortions in the insurance market. For example, it created a taxpayer-financed pathway for early retirement by facilitating transitions for Americans in their late 50s and early 60s to leave the workforce before Medicare eligibility. Obamacare initially included temporary federal subsidies for early retirees. Once exchanges launched, premium tax credits, guaranteed coverage, and capped premiums effectively subsidized early retirement.

The Congressional Budget Office warned years ago that such a program would encourage earlier retirement. A 2020 National Bureau of Economic Research study confirmed this: the law reduced labor force participation among 60- to 64-year-olds and shrank the near-elderly workforce by approximately 110,000 people between 2014 and 2018.

At a time of trillion-dollar deficits and rising entitlement costs, subsidizing early retirement represents a staggering misuse of taxpayer funds. Insurance market competition also declined. Many insurers withdrew from exchanges after struggling with the economics. A Government Accountability Office report found that the median number of insurers in individual markets dropped from 30 per state in 2011 to just 10 by 2022.

The Medicaid expansion component introduced further problems. Obamacare expanded Medicaid eligibility to able-bodied adults earning up to 138% of the federal poverty level, with Washington promising to cover 90% of costs—a much higher share than for legacy enrollees. States enrolled millions in droves, resulting in roughly 20 million people under the expansion. The Paragon Health Institute estimates that about 6.6 million were ineligible in 2024, costing federal taxpayers nearly $37 billion.

Fifteen years after the ACA’s passage, America’s healthcare system has become less affordable, less competitive, and less fiscally sustainable. Despite these shortcomings, many progressives see them as justification for even greater government control. Obama himself advocated for single-payer healthcare before becoming president—a stance that Obamacare was intended to advance. The law’s record suggests little reason to believe the next step would succeed.