Originally published May 7, 2014. Updated September 22, 2026.
President Barack Obama campaigned for expanded access to healthcare during his initial run for the presidency. He faced strong opposition from the Right, along with considerable political criticism and comparisons to dictators such as Adolf Hitler. After a hard-fought battle, the Affordable Care Act (ACA) was passed by Congress and signed into law in 2010. The ACA Marketplace began open enrollment in October 2013, with coverage beginning in January 2014.
The rollout of Healthcare.gov was shaky from the beginning. The website experienced significant technical problems, giving opponents of the law plenty of opportunity to criticize the new system. After improvements were made, people were finally able to log on and shop for coverage through the Marketplace. Healthcare facilities and community organizations also trained people to help consumers understand their options and enroll in coverage. These Marketplace Navigators and other certified assisters were trained to provide free assistance with the application and enrollment process.
Now, more than a decade later, the Affordable Care Act is no longer new. Millions of people have used Marketplace coverage, and the system has changed considerably since those first plans became available. But some of the concerns I wrote about in 2014 still deserve attention.
Here’s the ugly truth about “Obamacare” from what I’ve witnessed being in the healthcare industry… Having health insurance does not necessarily mean that you can walk into any hospital, see any doctor, or receive care without worrying about what you will owe. Marketplace plans have provider networks, and whether a particular hospital or physician is covered can depend on the specific insurance company and plan you selected. Some plans have narrower networks than others. Consumers are encouraged to check whether their doctors and hospitals are in-network before receiving care because using out-of-network providers can result in higher costs or, depending on the plan and service, no coverage at all.
That was one of the things I noticed when Marketplace coverage was first being used, and it remains an important part of understanding health insurance today. Having a recognizable insurance company on your card does not automatically mean that every facility that accepts that company accepts your particular Marketplace plan.
Then there is the issue of affordability.
In 2014, I wrote about families facing monthly premiums of $1,200 or more, sometimes alongside high deductibles and other out-of-pocket expenses. Today, Marketplace consumers still have to consider the entire cost of a plan, not just the monthly premium. A plan with a lower premium can have a higher deductible, copayments, coinsurance, or other out-of-pocket costs. The deductible is the amount you generally pay for covered services before the plan begins paying its share, although some services, including certain preventive services, may be covered before the deductible is met. Marketplace plans also have an annual out-of-pocket maximum for covered in-network care. For 2026, that maximum is $10,600 for an individual and $21,200 for a family.
When people say they have insurance, that does not necessarily mean they can afford to use it. The cost of Marketplace coverage also depends heavily on household income, household size, the plans available in a person’s area, and whether that person qualifies for financial assistance. Premium tax credits can lower monthly premiums, while cost-sharing reductions can lower deductibles, copayments, and coinsurance for eligible people who select qualifying plans.
There has also been an important change since I originally wrote this article. The additional Marketplace savings that were provided during the COVID-19 pandemic ended on December 31, 2025. People who qualify for Marketplace savings in 2026 may therefore pay more for their coverage than they did under those enhanced subsidies.
And then there is Medicaid. When I originally wrote this article in 2014, Georgia had not expanded Medicaid under the Affordable Care Act. That statement cannot be carried forward unchanged. Georgia now has Georgia Pathways to Coverage, a Medicaid program for certain adults ages 19 through 64 with household income up to 100 percent of the federal poverty level who are not otherwise eligible for traditional Medicaid and who meet qualifying activity requirements. Qualifying activities can include employment, education, job training, community service, and other approved activities.
That is different from the full Medicaid expansion adopted by many other states, so Georgia’s Medicaid landscape still does not look the same as it does in states that expanded traditional Medicaid eligibility under the ACA. But the situation is no longer accurately described as Georgia refusing to participate in Medicaid expansion.
The basic problem I was writing about in 2014, however, has not disappeared: access to insurance and access to affordable healthcare are not necessarily the same thing.
A person can have insurance and still face a deductible they cannot afford. They can have coverage and discover that the doctor or hospital they want to use is outside their network. They can have a Marketplace plan and still have to make difficult decisions about whether they can afford to actually use the coverage they purchased.
The Affordable Care Act created protections and expanded access to health insurance, including coverage for preexisting conditions and a set of essential health benefits required in Marketplace plans. It also created financial assistance for people who qualify. But insurance coverage alone does not eliminate the larger problem of healthcare costs.
That was my concern when I wrote this in 2014, and it is still a concern worth discussing in 2026. People should not have to choose between getting medical treatment and worrying about whether they can afford the bill afterward. We have made changes to the healthcare system, but the conversation about what makes healthcare truly affordable is far from over.
Update note: This article was originally published in 2014 and has been updated as of September 22, 2026, to reflect changes to the Affordable Care Act Marketplace, insurance costs and subsidies, provider networks, and Georgia’s Medicaid programs. The original perspective and historical context have been retained where possible.