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California’s ACA success is a testimonial for Medicare for All

April 23, 2020

Topics: Quote of the Day

By Peter V. Lee, Elliott S. Fisher, Kelly Green
Health Affairs Blog, April 20-21, 2020

One of the underlying principles of the Affordable Care Act of 2010 (ACA) is that public health is a public good. The landmark legislation dramatically changed how we view health care in the United States and brought meaningful health insurance coverage within reach of millions of Americans.

The nation made historic progress in reducing the number of uninsured Americans through sweeping reforms to Medicare, dramatic expansion of Medicaid, establishment of Marketplaces and subsidies in the individual market, and landmark health insurance market reforms. These were important achievements representing the biggest changes to coverage since the launch of Medicare and Medicaid more than 50 years ago. Serious challenges, however, remain. Concerns about health care affordability and access to needed services and health insurance coverage in the face of the COVID-19 pandemic are top of mind to consumers and voters across the nation. In addition, recent federal actions threaten to unravel some of the progress made, and there has been a resurgence of uninsurance in many states.

The experience of Covered California—California’s state-based Marketplace—shows that when the tools of the ACA are used effectively, progress is possible in coverage, affordability, quality, and delivery system improvement.

In a two-part blog post, we are highlighting the achievements, challenges, and lessons learned from California’s coverage expansion efforts and its Marketplace, Covered California. We believe these lessons are particularly relevant not only to the federal government and states, but to employers who are not effectively meeting the needs of many of the nearly 160 million Americans with employer-based coverage.

Lessons For Employer-Based Coverage

  • Premium contributions and cost sharing should be adjusted based on employee income.
  • Employers should promote benefit designs that are standardized and patient-centered.
  • Employers should enable employees to shop for value.
  • Employers should push for changes in underlying care delivery that will lower costs over the long term.

Looking Ahead

The Affordable Care Act enabled the nation to make great progress in expanding coverage. But, we cannot accept the progress made in California and other states as an end point. There is much more work to be done to enable millions more Americans to see their health care lives improve in the future. There are still 1.1 million uninsured Californians who are eligible to enroll through the Marketplace, Medi-Cal, or their employer—but are not now insured, whether by choice or due to lack of knowledge of what is available. Rising health care costs are a serious threat, and the affordability of health coverage and care remains a problem to many with and without coverage. Widespread racial and ethnic disparities remain largely unaddressed, as do marked variations in quality performance across plans and providers. On the delivery reform front, far too many enrollees continue to receive care in fragmented delivery models, subjecting them to lower quality and higher costs. These challenges are not unique to California and demonstrate intrinsic issues that states, the federal government, and employers need to work to resolve.

The current coronavirus epidemic poses perhaps the greatest threat to US health care in modern times, making predictions about future policy directions more challenging than ever. However, when policy makers consider the next round of health care reforms, we could well face a choice between a single-payer system that radically transforms the financing, coverage, organization, and delivery of care or more modest reforms that build on the current employer-based system. For the latter path to succeed, it will be important to take the lessons from the ACA and apply them to the employer sector. Otherwise, the next 10 years are likely to be marked by continued erosion in coverage and availability of care for the vast majority of Americans. In any future, however, dramatic changes will be necessary, so that all Americans can receive more financial help, have good benefits that bring value and quality, and experience a high-quality, cost-efficient care delivery system.

Part 1:

Part 2:


By Don McCanne, M.D.

California’s implementation of the Affordable Care Act was spectacularly successful, considering what they had to work with. Yet, because of the limitations of ACA, it has been a dismal failure when measured by the numbers who remain uninsured, by the lack of affordability of care for many of those who are insured, and by the perpetuation of the dysfunctions of the traditional American health care financing system.

As it turns out, the sector of health care coverage that supposedly was working so well – employer-sponsored health plans – frequently has not provided the protection that employees need. The authors do provide some suggestions for change, but they would have little impact since they are mere tweaks in a system that has fundamental design defects.

Buried in this two part analysis of California’s five year experiment with ACA is one sentence that says it all: “However, when policy makers consider the next round of health care reforms, we could well face a choice between a single-payer system that radically transforms the financing, coverage, organization, and delivery of care or more modest reforms that build on the current employer-based system.”

Modest reforms of the highly flawed employer-based system does not cut it, whereas enactment of a single payer improved Medicare for All is precisely what we need. Just read that one sentence and you can skip the rest. See, it really is simple.

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About the Commentator, Don McCanne

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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