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Policy background

Health care reform, explained.

Sixty years of federal law sit behind the plan you buy today. This page traces what changed, when, and which rules apply to coverage right now.

When people say health care reform in the United States they usually mean the Affordable Care Act, signed in March 2010. It was not the first reform and it has not been the last, but it is the law that reorganized how individuals and families buy coverage: it created the marketplaces, made health status irrelevant to whether you can buy a policy, defined a minimum benefit package, and attached income-based subsidies to the whole thing.

Since then the argument has mostly been about the subsidies rather than the structure. The protections have proved durable across three Supreme Court challenges and several changes of administration. The amount of financial help, and who qualifies for it, has moved several times, including for the 2026 plan year.

What applies to your coverage today

  • Insurers cannot refuse you, charge you more, or exclude treatment because of a pre-existing condition
  • Premiums can vary only by age, geography, family size, tobacco use, and the plan you pick, never by health status or gender
  • Every individual and small group plan covers the ten essential health benefits
  • No annual or lifetime dollar limits on essential health benefits
  • In-network preventive services are covered with no copay, coinsurance, or deductible
  • Children can stay on a parent plan until they turn 26, whether or not they live at home, are married, or are in school
  • Every plan has a cap on in-network out-of-pocket costs for covered essential benefits
  • Insurers that spend too little of your premium on actual care have to send rebates back to policyholders

How it got here

  1. 1965

    Medicare and Medicaid are created

    The Social Security Amendments of 1965 establish federal coverage for people 65 and older and a joint federal and state program for people with low income. Everything that follows is built on top of these two programs.

  2. 1986

    COBRA and the emergency treatment law

    One budget act gives many people the right to keep employer coverage temporarily after leaving a job, and requires hospitals with emergency departments to screen and stabilize anyone who comes in, regardless of ability to pay.

  3. 1996

    HIPAA

    The Health Insurance Portability and Accountability Act limits how long group plans can exclude pre-existing conditions and sets the privacy and security rules that still govern health information.

  4. 1997

    CHIP

    The Children Health Insurance Program covers children in families that earn too much for Medicaid but cannot readily afford private coverage.

  5. 2003

    Medicare Part D and health savings accounts

    The Medicare Modernization Act adds outpatient prescription drug coverage to Medicare and creates health savings accounts paired with high deductible plans.

  6. 2008

    Mental health parity

    Federal law requires plans that cover mental health and substance use treatment to apply the same financial requirements and treatment limits they apply to medical and surgical care.

  7. 2010

    The Affordable Care Act is signed

    Signed on March 23, 2010. The first provisions take effect within months: dependent coverage to age 26, no lifetime dollar limits on essential benefits, no pre-existing condition exclusions for children, an end to retroactive cancellations, and preventive care with no cost sharing.

  8. 2012

    The Supreme Court upholds the law and makes expansion optional

    In National Federation of Independent Business v. Sebelius, the Court upholds the individual mandate as a valid exercise of the taxing power but rules that states cannot be forced to expand Medicaid. Expansion becomes a state-by-state decision, and it still is.

  9. 2014

    The core of the law takes effect

    Marketplaces open for January 1 coverage. Guaranteed issue and community rating begin, essential health benefits become mandatory, premium tax credits and cost-sharing reductions start flowing, and the first states expand Medicaid.

  10. 2015

    Subsidies survive a second challenge

    King v. Burwell confirms that premium tax credits are available in every state, including the states that use the federal marketplace rather than running their own.

  11. 2019

    The federal penalty goes to zero

    A 2017 tax law set the individual mandate penalty to $0 starting with the 2019 tax year. The requirement to have coverage stayed on the books; the federal fine for not having it did not. A handful of states have since adopted their own requirement.

  12. 2021

    Larger subsidies and a third court test

    The American Rescue Plan temporarily increases premium tax credits and suspends the income ceiling on eligibility. In California v. Texas, the Supreme Court leaves the law standing, ruling that the challengers lacked standing to sue.

  13. 2022

    The family glitch fix and the Inflation Reduction Act

    A Treasury rule change lets family members qualify for marketplace subsidies when the family cost of job-based coverage is unaffordable, not just the employee-only cost. The Inflation Reduction Act extends the larger premium tax credits through 2025 and adds Medicare drug provisions, including a cap on insulin cost sharing and, from 2025, an annual out-of-pocket cap in Part D.

  14. 2026

    The temporary subsidy increase ends

    The enhanced premium tax credits expired at the end of 2025 and were not extended, so for 2026 the subsidy formula reverted to the original Affordable Care Act schedule and the income ceiling at 400 percent of the federal poverty level returned. Marketplace premiums that people actually pay rose sharply as a result, and enrollment fell. The underlying consumer protections, from guaranteed issue to the essential health benefits, were not changed.

See how marketplace plans workCheck the rules in my state

See what you qualify for

Subsidy rules change; your county plan list is the only place to see what they mean for you. Enter your ZIP code to check.

Where things stand

Four figures that describe the system now.

year the Affordable Care Act was signed
2010
essential health benefits every ACA plan covers
10
states including DC that have expanded Medicaid
41
federal penalty for going without coverage since 2019
$0

Good to know

Common questions about health care reform.

Is the Affordable Care Act still in effect?
Yes. The law has survived three trips to the Supreme Court and remains the framework for individual and small group health insurance in the United States. Guaranteed issue, the essential health benefits, the ban on pre-existing condition exclusions, dependent coverage to 26, free in-network preventive care, and the out-of-pocket maximum all still apply. What has changed over time is mostly the money: how large the premium tax credits are and who qualifies for them.
Do I still get fined for going without coverage?
There is no federal penalty. It was reduced to $0 starting with the 2019 tax year and has stayed there. A few states have adopted their own requirement instead: California, Massachusetts, New Jersey, Rhode Island, and the District of Columbia impose a state penalty, and Vermont asks residents to report coverage without attaching a penalty. If you live in one of those places, check the current state rule before you decide to go uninsured.
What changed about subsidies for 2026?
The larger premium tax credits first enacted in 2021 and extended through 2025 expired at the end of 2025. For 2026, the credit is calculated under the original Affordable Care Act schedule, which asks households to pay a larger share of their income toward the benchmark plan, and eligibility again cuts off above 400 percent of the federal poverty level. Many people still qualify for a credit, but the amount is smaller than it was, and households just above the income line no longer receive one at all. Because Congress can revisit this, check what applies for the plan year you are shopping.
What is Medicaid expansion and does my state have it?
Expansion opens Medicaid to adults under 65 with income up to 138 percent of the federal poverty level, with the federal government paying the large majority of the cost. The 2012 Supreme Court decision made it optional, and 41 states including the District of Columbia have adopted it while 10 have not. In a state that has not expanded, some adults fall into a coverage gap where they earn too much for that state Medicaid rules and too little for a marketplace subsidy.
Does reform affect employer coverage?
Yes, though less visibly. Employers with 50 or more full-time equivalent employees have to offer affordable coverage that meets a minimum value standard or face a payment. Job-based plans also have to cover dependents to 26, cover preventive care with no cost sharing, cap in-network out-of-pocket costs, and drop lifetime and annual dollar limits on essential benefits. Large self-funded plans are exempt from some rules, such as the essential health benefits package, but not from those.
Where can I read the official rules?
HealthCare.gov is the plain-language starting point for individual coverage, and CMS.gov publishes the regulations, fact sheets, and annual notices of benefit and payment parameters that set the year-to-year details. State-run marketplaces publish their own rules and deadlines, which can differ from the federal ones.

Rules aside

See the plans and savings available where you live.

Enter your ZIP code to compare marketplace coverage for your county under the rules in effect now.

Compare plans and any premium tax credit you qualify for, at no cost.