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Eight years of promises — some to save it, others to destroy it — paint the Affordable Care Act's legacy.

Opinions were split when former President Barack Obama signed the comprehensive health reform law, often called the ACA or Obamacare, on March 23, 2010.

Since then, the ACA has undergone changes and attempts to scrap it. Yet nearly 11.8 million Americans and 229,000 Tennesseans rely on ACA health insurance plans, and more Americans than ever — 54 per- cent — feel positive about the law.

When the HealthCare.gov marketplace launched in 2013, 44 million Americans under age 65 were uninsured. That number dropped 36 percent to less than 28 million by the end of 2016, according to the nonprofit Kaiser Family Foundation.

But in November 2013, a month after signups began, only 33 percent of Americans favored the ACA, according to a Kaiser Health Tracking Poll.

Initial sign-ups were marred by system crashes and an influx of Medicaid enrollees in states that decided to use federal funds offered through the ACA to expand the entitlement program, which bolstered the conservative, anti-spending argument.

"Even though the federal government promises to pay 100 percent for the first three years and 90 percent thereafter, I think it is probably unrealistic to expect that promise to be fulfilled in the long term, simply because of the financial status that the federal government is in," Georgia Gov. Nathan Deal said in September 2013.

Over the years, fewer healthy people than expected enrolled and premiums soared. Insurers left the marketplace over uncertainty, and the number of plans dwindled. Controversy, mostly over regulations and costs, plagued the law that promised "affordable" health care.

Many low-wage workers fell into a gap in states such as Tennessee, Georgia and Alabama that didn't expand Medicaid. Others who made too much money for tax credits or subsidies found the plans too expensive.

But other aspects of the law were cherished. Now insurance companies couldn't refuse people with pre-existing conditions, children got to stay on their parents' insurance until age 26 and many preventative services became free.

"Not that this law is the end-all be-all, but the law has dramatically changed the lives of so many people," said Andy Slavitt, who served as the administrator for the U.S. Centers for Medicare and Medicaid Services from 2015-2017, where he oversaw implementation of the ACA.

"If you had told me eight years later that we'd have solved all of those problems, even if you told me we haven't solved every problem, I would have felt like that was an enormous amount of progress," he said. "But I think the country is hungry for more progress."

How to achieve that progress probably depends on your political philosophy.

In the past year, a Republican-endorsed tax bill eliminated the individual mandate that forced people to buy ACA-compliant health insurance or pay a penalty, a provision that was long detested and deemed an unfair tax on working Americans.

The Trump administration cut most of the ACA's advertising funds, shortened the enrollment period and ended payments to insurers called cost-sharing subsidies. Advocates of the law feared those moves would result in high numbers of uninsured, but enrollment fell a moderate 3.7 percent.

Further measures to allow cheaper, short-term insurance plans appeal to those who can't or don't want to pay for all of the ACA's benefits.

But opponents fear these plans will draw more healthy people away from the market, leaving the insurance companies that offer ACA plans to shoulder the costs of sicker individuals. As companies raise prices in response, these already expensive plans will become even less affordable, and more people will be left without health insurance.

Sen. Lamar Alexander, R-Tenn., chairman of the Senate's health committee, emphasized the situation's gravity and need for more affordable health insurance during a news conference on Wednesday.

"We're talking today about the plumber who makes $60,000, who pays for all of his own insurance, and whose insurance bill is $20,000," he said. "We're talking about Marty, a farmer in Tennessee, who told me recently her insurance had gone from $300 a month to $1,300 a month."

Alexander has been working alongside other Republican and Democratic Congress members since August to develop a plan to stabilize the individual market. The bill appeared on track to be included in the omnibus spending bill Congress approved this week, until it hit a major hangup: abortion rights — the same argument that nearly prevented the ACA from becoming a law in the first place.

Now, Republicans want to add stricter language to the bill called the Hyde Amendment, which prohibits the use of federal funds to pay for abortion except to save a woman's life, that they feel was left out of the original ACA. Democrats find any addition of such language unacceptable.

"It is disappointing that an opportunity to lower health insurance rates by up to 40 percent for working Americans has turned into a debate about the mechanics of funding for abortion coverage," Alexander said. "Every year since 1976, Republicans and Democrats have agreed that federal dollars cannot be used to fund elective abortions, and our proposal does not change that."

Dr. Brent Morris, a pediatrician in Chattanooga and ACA advocate, stood on the federal courthouse lawn downtown on Thursday to voice his fears over the current climate.

"We've been working on this for a couple years now to try and make the ACA survive," he said. "Over the last eight years, we've seen real progress — our biggest concern overall is that we're turning back the clock."

Contact staff writer Elizabeth Fite at efite@timesfreepress.com or 423-757-6673.

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