March 23 marks 10 years since President Obama signed the Affordable Care Act (ACA) into law. Over this decade, the law has dramatically reduced the number of uninsured people in the United States, eliminated many unfair private insurance practices, expanded the scope of what health insurance covers, instituted new patient protections, supported the U.S. health care system’s ability to better deal with crises like the COVID-19 outbreak, and generally led to improved health and economic well-being for millions of people.

More specifically, it has expanded access to sexual and reproductive health services in numerous ways. Yet, continued challenges from the Trump administration and other conservative policymakers threaten its future.

ACA Victories

The ACA has supported millions of people’s sexual and reproductive health by expanding health coverage and the scope of services covered by insurers. Specifically, the law has:

Threats to the ACA

Conservative lawmakers are pursuing several policies that jeopardize both the ACA writ large and its specific protections for sexual and reproductive health. If executed, these policies would undermine the important achievements in health care accessibility and affordability made possible by the ACA.

In 2018, the Trump administration announced a policy that, if allowed to go into effect, would weaken the contraceptive coverage guarantee by exempting employers, schools, individuals and insurers with religious or moral objections to contraception. As the Guttmacher Institute and others have argued, the rules would compromise women’s ability to obtain contraceptive methods, services and counseling and heighten their risk of unintended pregnancy and the negative health, social and economic consequences that can result. This spring, the U.S. Supreme Court will rule on the legality of this policy.

Meanwhile, conservative policymakers are pushing for several changes to Medicaid that threaten to undo coverage expansions made possible by the ACA. The Trump administration is approving “waivers” of federal law that take away Medicaid coverage from people who do not engage in paid work, educational pursuits or other related activities for a certain number of hours per month. State and federal policymakers are also seeking to undermine Medicaid by proposing unprecedented caps on federal funding for the program in the form of a fixed sum (a block grant), rather than based on reimbursement. Work requirements and block grants would deny people sexual and reproductive health care by forcing them out of Medicaid.

Finally, a potentially even bigger ACA-related case will be heard by the Supreme Court in fall 2020, with a likely decision in 2021. A group of 20 states, led by Texas, is seeking to overturn the entire ACA by arguing that when Congress eliminated the ACA’s tax penalty for not having insurance in 2017, it effectively invalidated the rest of the law. The Trump administration is largely siding with Texas, while 17 other states, led by California, are defending the ACA in court. A decision that strikes down most or all of the ACA would lead to massive upheavals in the U.S. health care system, including elimination of all of the ACA’s gains for sexual and reproductive health.

These ongoing threats have also interfered with and distracted from efforts to build on the progress of the ACA and further improve the U.S. health care system. Millions of people are still uninsured, important services like abortion and infertility care are often excluded from coverage, access to providers is limited in many areas and for many services, and people’s health and rights still often take a back seat to bureaucracy and the financial bottom line. Much more needs to be done to ensure the health care system nationwide fully meets people’s sexual and reproductive needs and rights, as well as their broader health care needs.