The complexity of the Affordable Care Act (ACA) and its many provisions has left ample opportunity for misrepresentation. But the harsh criticisms of its opponents have rarely taken into account the range of problems the ACA was created to address:
* the highest per capita expenditures of any health care system in the world
* consistently worse outcomes on measures such as infant mortality rate than most other developed nations
* increasing numbers of uninsured Americans each year, to over 50 million in 2009, the year before passage of the ACA
* unsustainable annual increases in health insurance premiums and drugs costs, leading to astonishing rates of medical bankruptcy
* a Medicare reimbursement process that rewarded the volume of care provided rather than the effectiveness of that care
What's working? Implementation of the first ACA provisions began in 2010, with new ones going into effect each year since. But most people really started paying attention with the opening of state and federal exchanges in October 2013. After a rocky rollout because of a plethora of Web site failures, by the end of the first quarter of 2014 the percentage of uninsured Americans had dropped from between 18% and 21% (depending on the estimate) to between 13% and 16%-put another way, there were 8 to 11 million more insured people by the end of the first open enrollment period, with around half of these purchasing insurance on the exchanges and half joining Medicaid rolls through the expansion of eligibility in states that opted to comply with this ACA provision.
Other ACA provisions have increased access to affordable insurance for those with preexisting conditions and for adults 26 and under, provided full coverage of many types of preventive care, shown initial promise in reducing yearly increases in health care spending, tied Medicare reimbursements to quality measures such as the reduction of hospital-acquired infections, and spurred innovation and investment in new models of care such as medical homes and accountable care organizations.
War of attrition. In the years since 2010, there have been many challenges, including a 2012 Supreme Court case in which the court upheld the law while allowing states to decide whether they would comply with the expansion of Medicaid eligibility. (Estimates suggest that the 25 states that did not expand Medicaid eligibility in January 2014 cost as many as 5 million Americans coverage.) More recently, the November 2014 midterm elections, resulting in Republican control of both houses of Congress, opened the door for legislation designed to reduce or cut funding to several key provisions. In addition, the Supreme Court recently announced that during the current term it will hear a case, King v. Burwell, that could endanger the subsidies that enable millions to purchase insurance via the federal health care exchanges. The loss of affordable insurance options for these individuals-as well as potential secondary effects on the entire law's financial viability-could be catastrophic.
If these attacks on the ACA are weathered, there will inevitably be a continuing need to fine-tune numerous provisions, such as the fairness and accuracy of quality measures used to determine hospital reimbursement by Medicare. And the U.S. health care system will remain an unnecessarily complex patchwork of payment models that will continue to cost us billions each year in administrative fees and leave the consumer often unsure of the true cost of any potential treatment. But in the absence of a proposal for a better solution (or realistic hopes of selling the U.S. public on a single-payer system), partisan attacks on the ACA-as opposed to collaborative efforts to improve aspects of the law-seem increasingly a form of vandalism and their effects likely to harm those who have already been helped.-Jacob Molyneux, senior editor