NORTH ADAMS >> The Affordable Care Act, aka Obamacare, is about to complete its third open-enrollment period. Despite surviving numerous challenges including technical malfunctions in the initial enrollment period, two Supreme Court challenges, and dozens of repeal efforts in Congress, it may now face its biggest challenge yet in this year's presidential election.

Since the Affordable Care Act became law in 2010 we have seen the largest reduction in the uninsured in four decades, about 16.4 million uninsured people have gained health coverage. Those gains come primarily from individuals now being eligible to receive assistance to help purchase health insurance, young adults who can stay on their parents' plans until they turn 26, and optional state Medicaid expansions.

Fueled by the upcoming national election though, the ACA remains quite divisive. Jonathan Cohn and Mark Blumenthal writing in The Huffington Post observe: "The first and more obvious factor is partisanship. No single characteristic better predicts how a person feels about the health care law than his or her partisan affiliation. Republicans tend to think the law is a failure, while Democrats tend to think it's a success...The other factor is the changes that people see in their health insurance every day — changes that often have nothing to do with the Affordable Care Act. Many of the problems that spark complaints about Obamacare, such as rising out-of-pocket costs, might be worse if the law did not exist."


In regard to public perception, a recent Kaiser Family Foundation poll found. surprisingly, that the uninsured are slightly less favorable toward the ACA than is the public overall. Drew Altman writing in the Wall Street Journal observed: "This may seem counterintuitive, as the uninsured benefit most from the ACA. But there are several reasons: The uninsured generally believe that coverage will not be affordable because it never has been before; they may not know that they can get help paying for it under the ACA; and they face a penalty if they do not purchase coverage."

Threats continue

I have seen this reaction. In 2009, I helped a self-employed man with his annual redetermination application for Commonwealth Care, a Massachusetts state health coverage program implemented under our landmark health care law that helped income eligible residents pay for health coverage. If not for that program, he would not have been able to afford health insurance.

He told me that he was against the Obama administration's proposal for the Affordable Care Act, explaining that he "didn't want the government interfering with his health care." I gently explained to him that Commonwealth Care was a governmental program and the Affordable Care Act was based on what we accomplished in Massachusetts. He was surprised.

One of the most respected voices in health policy in the country is John E. McDonough, currently a professor at the Harvard School of Public Health. He is a former Massachusetts state legislator and he has served in many important state and federal legislative health policy roles.

In his blog,, he cautions us that despite President Obama's veto of the most recent attempt to repeal the Affordable Care Act, the law still faces peril: "By successfully using budget reconciliation (requiring only 51 Senate votes for passage) to win congressional approval of a bill to wreck health reform, Republicans have proven, without doubt, that if they control the White House, Senate, and House in January 2017 they can — and will — dismantle the most important piece of U.S. social policy legislation since the passage of Medicare and Medicaid in 1965, and do so with no regard or effort to ameliorate the deadly consequences of their action."

It has been observed that in no other field of public policy is there as much hyperbole and misinformation as there is in health care. This has certainly been on display this unpredictable election year, so far dominated by a restless and rebellious electorate, along with a public that still doesn't understand the potential benefits of this most significant legislation. Given these prevailing forces, this year the Affordable Care Act may face its biggest challenge yet.

Charles Joffe-Halpern was executive director of Ecu-Health Care from 1995-2015 and a member of the Board of Directors of the Massachusetts Health Connector, 2006-2007.