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Health Affairs on ACA at 10: A celebration of cruel mediocrity

March 3, 2020

Topics: Quote of the Day

How Have ACA Insurance Expansions Affected Health Outcomes? Findings From The Literature

Health Affairs, March 2020

A growing body of literature examining the effects of the Affordable Care Act (ACA) on nonelderly adults provides promising evidence of improvements in health outcomes through insurance expansions.

However, not all studies reported a significant positive relationship between ACA provisions that expanded insurance coverage and health status.


Did The ACA Lower Americans’ Financial Barriers To Health Care?

We found that the Affordable Care Act generated substantial, widespread improvements in protecting Americans against the financial risks of illness. The coverage expansions reduced uninsurance rates, especially relative to earlier forecasts; improved access to care; and lowered out-of-pocket spending.

But subsequent court decisions and congressional and executive branch actions have left millions uninsured and allowed the risk of inadequate insurance to resurface.


Women’s Coverage, Utilization, Affordability, And Health After The ACA: A Review Of The Literature

This literature review summarizes evidence on the law’s effects on women’s health care and health and finds improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes.

Despite major progress after the Affordable Care Act’s implementation, barriers to coverage, access, and affordability remain, and serious threats to women’s health still exist.


The ACA’s Impact On Racial And Ethnic Disparities In Health Insurance Coverage And Access To Care

In the years since the law went into effect, insurance coverage has increased significantly for all racial/ethnic groups.

Despite these improvements, a large number of adults remain uninsured, and the uninsurance rate among blacks and Hispanics is substantially higher than the rate among whites.


How The ACA Dented The Cost Curve

Numerous provisions of the Affordable Care Act (ACA) were designed to make health care more affordable…

yet the act’s cumulative effects on health care costs are still debated.


Transforming Medicare’s Payment Systems: Progress Shaped By The ACA

We conducted a narrative review of these payment reforms, finding that several programs generated modest savings while maintaining or improving the quality of care, but they had high dropout rates.

In general, evidence for other APMs is less conclusive, and whether the reforms spurred similar changes in the private sector remains anecdotal.


The Changing Landscape Of Primary Care: Effects Of The ACA And Other Efforts Over The Past Decade

Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade…

though evaluations showed little progress in spending or quality outcomes.


The ACA’s Individual Mandate In Retrospect: What Did It Do, And Where Do We Go From Here?

This article reviews recent research on the mandate’s effects, concluding that the mandate meaningfully increased insurance coverage, but likely by less than was projected before implementation.

These coverage gains are likely to erode as mandate repeal takes hold.


The ACA’s Effect On The Individual Insurance Market

The vision of the Affordable Care Act (ACA) for a reformed individual health insurance market included requirements and incentives for insurers to manage risk instead of avoiding it, minimum standards for coverage adequacy, income-related subsidies, managed competition through health insurance Marketplaces, and new programs to promote insurer competition.

However, in the wake of a political backlash against the law and unstinting opposition from many federal and state policy makers, the administration of President Barack Obama and Congress made several decisions that weakened the law’s foundations. The law’s opponents further undermined market stability through legal challenges that created uncertainty about the future of the law.


How The ACA Reframed The Prescription Drug Market And Set The Stage For Current Reform Efforts

Looking back a decade after the Affordable Care Act became law, we found that new drug approvals have accelerated and the therapeutic advances embodied in some novel medicines are substantial—as are the prices that companies are charging for them.

The lack of affordability of prescription drugs has become an increasing challenge for American patients and payers, particularly those with limited budgets.


The Ten Years’ War: Politics, Partisanship, And The ACA

After decades of failed efforts to overhaul American health care, the Affordable Care Act’s 2010 enactment was the most important health reform achievement since Medicare and Medicaid’s passage.

But ten years later, ACA politics are more tenuous than triumphal, and the ACA has not escaped the controversy that surrounded its enactment.


The ACA And The Courts: Litigation’s Effects On The Law’s Implementation And Beyond

Litigation over the law began on the day of its enactment and has been a constant in the decade since.

Although the law has survived these challenges, its effectiveness has been hobbled.


Health Insurance Coverage: What Comes After The ACA?

By Benjamin D. Sommers

The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016.

But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA’s coverage gains since 2017.


There is no obvious market-based remedy for the increasing financial burden experienced by many people with private insurance.


Finally, no discussion of coverage and access to care would be complete without considering more dramatic proposals to overhaul the US health insurance system. Under the broad rubric of “single payer” or “Medicare for All,” 2020 presidential candidates have floated a variety of approaches ranging from Medicare buy-in with a gradual transition to universal coverage, to the elimination of all private insurance in the US. A full assessment of the political and economic considerations of such proposals is well beyond the scope of this article, but these considerations warrant extensive debate. To vastly oversimplify matters, a publicly financed single-payer system would offer important advantages in terms of its universality, administrative efficiency, and potential for wringing price concessions from providers, hospitals, and drug and device makers that would get the US closer to its peers in terms of health care costs. But it would also involve enormous political and logistical challenges—particularly if it entailed eliminating private coverage for the over 150 million Americans currently insured through their employers—as well as shifting trillions of dollars in health care spending from the private sector to the federal government.



By Don McCanne, M.D.

The March issue of Health Affairs is a special edition that looks at the impact of the Affordable Care Act as it turns 10. Most of the articles are listed above with a short paragraph on a policy goal and a second short paragraph on the progress towards that goal. Although the policy gains are celebrated, it is difficult to see how anyone could celebrate the progress when many of the results are cruelly mediocre at best, and collectively should represent a profound disappointment for the policy community.

There is a glimmer of hope in the discussion of Benjamin Sommers on what comes after the ACA. For those who say that we must preserve and protect our private insurance plans, Sommers states, “There is no obvious market-based remedy for the increasing financial burden experienced by many people with private insurance.” You private insurance supporters, listen up!

Sommers also writes, “a publicly financed single-payer system would offer important advantages in terms of its universality, administrative efficiency, and potential for wringing price concessions from providers, hospitals, and drug and device makers that would get the US closer to its peers in terms of health care costs,” though he concedes that there are “enormous political and logistical challenges.”

Over a decade ago, as the politics were aligning behind what became the Patient Protection and Affordable Care Act, many of us were sounding the alarm that the policies supported were quite unsatisfactory, and that proceeding down that path would delay by another decade effective reforms that we desperately needed. What has happened since then is that far too many of us have experienced financial hardship, including personal bankruptcy, physical suffering and even death because of a system design that significantly impairs access to essential health care, even though we were already spending enough money to meet the goals of health care justice for all.

On June 11, 2009, I gave the keynote address at the annual meeting of the Health Care Council of Orange County – a group that was well informed on health policy.

I opened with the following questions directed to the audience:

How many here believe that it is probable – not certain, but probable – that Congress will pass health care reform and President Obama will sign it this year?
(Most individuals raised a hand)

How many believe that the legislation will provide insurance coverage to everyone or almost everyone?
(Not one hand went up)

How many believe that the legislation will be effective in slowing the rate of health care cost increases?
(Not one hand went up)

Following is an excerpt from a Quote of the Day that I wrote shortly after that meeting:

Everyone agrees that it is critical that we do something now to slow the rate of increases in health care costs. While addressing costs, most of us also agree that we must bring everyone in under the umbrella of financial security when facing health care needs. Since neglect of these issues has created the crisis we face, you would think that Congress and the administration would be busy attempting to fix these problems.

Congress is busy all right. But no one at the Health Care Council has been fooled. We are going to end up with legislation that will be labeled “health reform,” but the twin crises of rising costs and inadequate insurance will still be with us. Congress and the President will walk away, pretending that they did something, and it will take years or decades of more suffering and hardship before our leaders revisit the problems and finally do the right thing.

Sheer madness!


Let’s not allow the neoliberals to waste another decade continuing to take us down that path that is studded with financial hardship, physical suffering, and even death. Single payer Medicare for All. Now!

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About the Commentator, Don McCanne

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Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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