The original intention of the ACA was to end a multi-generational push to reform the American health care system. Mr. Obama cited the fact that the United States is the only wealthy industrialized nation in the world without universal healthcare insurance coverage as well as a series of stories highlighting the dangers of having a pre-existing condition with private insurance. He proposed the ACA as a plan that, "[would] provide more security and stability to those who have health insurance… [would] provide insurance for those who don't, and [would] slow the growth of health care costs for our families, our businesses, and our government."
As a piece of legislation, however, the ACA has received a great deal of criticism. Many of its largest critics, predominantly conservatives, have condemned the act as a job-killer, and Republican governors were originally resolute in their stance of rejecting federal funding for the state-based programs. However, studies have shown that the ACA has not, in fact, had a significant deleterious effect on employer responsibilities.
The most criticism for the act, however, was focused on one requirement in particular. The requirement that contraceptives be covered without any co-payments has received more than 147,000 comments on online federal portals for the ACA. Access to contraceptives has always been controversial in the United States, especially women's access to birth control. Some have extolled the value of women's access to birth control, calling its proliferation, "nothing short of revolutionary for women and society". However, others have condemned it as a violation of religious freedom.
This controversy has led to court cases questioning the validity of the ACA. In the landmark Court case National Federation of Independent Businesses v. Sebelius, the Court upheld the ACA as a whole. However, further cases have been put forward, arguing that the contraceptive requirements violate religious freedom. Nuns from the Little Sisters of the Poor filed a complaint against the ACA's contraceptive mandate in 2013, asserting that the law violated their exercising of religious freedom. Although the ACA allows for religious employers to sign a form allowing employees to receive free contraceptive coverage from a third party, some maintain their argument that, "signing that piece of paper was the moral equivalent of condoning birth control." The Supreme Court has yet to hear arguments in the case, but several notable groups and people have demonstrated their support for the Little Sisters, including 207 Congress members and Pope Francis.
Ruling in this case will, in a roundabout way, be a test of how effective a policy the ACA is. The Act has attempted to avoid issues of religious freedom by offering alternative methods of ensuring contraception for employees, but the question the Court will rule on will be whether or not the government is placing a "substantial burden" on the Little Sisters' exercise of religion.
Legal scholars are predicting that the Court will rule against the Little Sisters, and find the ACA contraception mandate not a religious freedom violation. Health Affairs reported that Supreme Court precedent from 1990 has protected "neutral, generally applicable laws" from being a violation of religious freedom. But regardless of the ruling in this case, the ACA has already had a profound effect on the way Americans get contraceptives. A study from Health Affairs released last year showed that, following the ACA mandated requirement of full coverage for contraceptives, out-of-pocket spending on the pill decreased by $1.4 billion per year. The study showed that Americans were spending less on contraceptives across the board, decreasing the amount women spent out-of-pocket on health care from 30-44 percent to much lower. Furthermore, because the US health system still involves competition between insurance plans, the impact of this mandate has likely had a significant impact on women's costs through private health plans as well.
The Affordable Care Act is a culmination of decades of policy work, and the incorporation of a contraception mandate is by no means a simple decision. Criticisms of the act and the mandate in particular demonstrate fractured opinions in American society surrounding the role of birth control and contraceptives in public policy. However, the statistics show that the ACA has had a profound impact on the lives of individuals across the country, and regardless of religious freedom claims, these changes will continue to reverberate around the country.