Six years in, Affordable Care Act appears likely to go the distance

Last month I was so busy doing my income taxes and preparing MACRA presentations for conferences in Maine, Connecticut and Pennsylvania, I forgot to pause and reflect on the Affordable Care Act turning 6 years old on March 23. Kent Bottles

What is the current state of the ACA? Will the next president repeal or replace the ACA? Is it a success or failure?

Each of the Republican candidates for the presidential nomination vow to repeal the most important healthcare law since Medicare was passed in 1965. Hillary Clinton says she will make changes to the ACA, and Bernie Sanders proclaims that he will replace the ACA with universal coverage. Before we predict which scenario we can expect in 2017, perhaps we should take stock of the current state of the ACA.

The two main goals of the ACA are to increase the number of Americans who have health insurance and to increase the value of the care they receive.


The uninsured rate for Americans has dropped from 16 percent in 2010 before the ACA was passed to 9 percenttoday in 2016. More than 20 million Americans now have health insurance, and 12.7 million have obtained coverage through the ACA exchanges. More than 3 million young Americans are covered until age 26 through their parents’ plans, and 6 million have insurance in the 32 states and the District of Columbia that chose to expand Medicaid.

A recent Robert Wood Johnson Foundation white paperconcludes states that expanded Medicaid under the ACA provisions have prospered in ways that can be measured. Compared to states that refused expansion, these states exhibit better job growth (2.4 percent vs. 1.8 percent) and less spending on Medicaid (3.4 percent vs. 6.9 percent). It also reported that hospitals in states that did expand Medicaid saved $7.4 billion by avoiding uncompensated care.

Proponents of the law also point out that more than 10 million seniors saved $20.8 billion on prescription drugs and more than 39 million seniors received free preventive services without having to pay a co-pay, according to the Centers for Medicare & Medicare Services.

The second goal of the ACA--to increase the value of healthcare--is much harder to assess. There has been a healthcare cost deceleration since the passage of the ACA in 2010, but cause and effect is not straightforward. Estimates of the effect of the American recession on this deceleration have ranged from 37 percent to 77 percent, according to the Kaiser Family Foundation. If the slow down in healthcare spending is due to the recession, the ACA cannot take credit for the cost savings.

Recent analyses have pointed to different causes of healthcare cost deceleration in employer-sponsored healthcare versus Medicare, as Peter Orzag pointed out in his recent keynote speech at the Jefferson University Population Health Colloquium in Philadelphia. Other studies, he noted, have focused on waste in post-acute care as a key area to better understand. The ACA’s pilot value-based provider payment programs have probably helped slow the increase in the cost of healthcare, but how much is due to the ACA clearly needs further study.

While proponents of the ACA can point to some accomplishments, especially in the area of coverage, the law continues to be controversial. Kaiser Family Foundation tracking polls have established that about half of Americans support the ACA and half oppose it. The House of Representatives has voted to repeal the law more than 62 times, but as long as a Democrat is in the White House it will not be repealed.

Opponents of the ACA took the occasion of the sixth anniversary of its passage to point out its failures and shortcomings:

  • The number of young, healthy people signing up for insurance through the exchanges has been less than anticipated
  • Consolidation of all aspects of the industry has been a response to the ACA

As we have seen, arguments can be made that the ACA is a success--and arguments can be made that it is a failure. Should healthcare leaders prepare for its repeal if a Republican is elected president in November?

I don’t think so. Even if a Republican is elected president, the composition of Congress will make it difficult to repeal the law. Taking away health insurance from people who recently obtained it for the first time would create an enormous political backlash. The entire industry has spent six years responding to the healthcare reforms spelled out in the ACA, and it does not want to endure the chaos of starting over again. For better or worse, the industry will continue to adapt to the transition from fee-for-service to value-based payment programs.

Kent Bottles, M.D., is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.