The Past and Future of the Affordable Care Act

In this issue of JAMA, President Barack Obama has provided a comprehensive assessment of the Affordable Care Act (ACA),1 which as he indicates is the most comprehensive health care reform since Medicare. In 1965, Medicare passed in the House with a 313-115 vote and in the Senate with a 68-21 vote. By contrast, the ACA barely reached the filibusterproof threshold of 60 votes in the Senate and passed the House with a 219-212 vote. As President Obama has chronicled, that the ACA passed at all, let alone survived multiple Supreme Court and Congressional challenges, is a political miracle. Despite these compromises and partial setbacks, the primary goal of the ACA has been met: to expand the number of people with health insurance. With an estimated expansion in health insurance of 20 million individuals, President Obama is right to claim credit for the ACA. But counting up the number of individuals with insurance is not enough to assess if the ACA was a success. Perhaps the more important measures are whether the ACA improved health and saved money. For example, the 2008 Oregon Health Insurance Experiment, a randomized trial of Medicaid expansion, found that newly insured individuals used more hospital care, were given more prescription drugs, and received more preventive care than before receiving insurance. Individuals were less likely to be diagnosed with depression and experienced less medical debt, a leading source of bankruptcy. Although almost everyone reported being able to see a physician, hypertension and diabetes control did not change relative to the control group, overall medical spending increased by $1000 per person annually, and emergency department use increased by 40%.2,3 These findings from Oregon, in contrast to claims that were made to justify the ACA,4 suggest both optimism and caution for the ACA’s primary goal of expanding insurance coverage and the related consequences. Even Medicaid—an insurance program that offers lower payment rates and narrower networks than commercial insurers and Medicare—is valuable but possibly less valuable than had been hoped. In other words, providing health insurance may not automatically result in an improvement in health when health care systems are fragmented and inefficient. A central feature of the ACA has been the accountable care organization (ACO), the goals of which were to reduce fragmentation and inefficiency by encouraging the innovative redesign of primary health care, measuring health outcomes, and relying on physician-led expert systems and treatment pathways. Many ACOs have proven to be successful in achieving improvements in health process measures, timely access to physicians, and overall patient satisfaction.5,6 Among the challenges facing current ACOs are that some of these organizations do not know their cost structure, have little control over loosely affiliated physicians, and are prohibited from implementing patient cost-sharing for unwarranted treatments. Yet the continued growth of ACO contracts, even in commercial markets, suggests continued optimism by both health care organizations and health care professionals, as well as by insurance companies for this new organizational structure. A second key objective of the ACA was to make health care affordable. President Obama’s Special Communication reports substantially slower increases in health care spending during the first 5 years of the ACA (2010-2014).1 One question is whether this slowing occurred because of the ACA, or because of other factors unrelated to the ACA, such as the longlasting effects of the recession, or the increase in amounts of deductibles and copays. It seems unlikely that, at least for the period 2010-2014, the ACA can claim much credit for the slowdown in the increase in spending growth. The slowing of health care spending began in 2006, before both the ACA was passed and the onset of the 2008 recession. A previous study suggested that the specific cost-saving components of the ACA during this period could not have accounted for this moderation in growth.7 For example, even though ACOs have been expanding rapidly in recent years, their short-term effect on cost growth has been modest, with estimates generally less than 3%.8,9 So if not the ACA, why was inflation-adjusted Medicare spending declining on a per-capita basis during 2010-2014? During the recession, Medicare enrollees were insulated from higher copayments and deductibles, and faced neither employment risk nor loss of health insurance. Instead, the early enthusiasm for many then-new technologies developed in the 1990s and 2000s ebbed beginning in 2006, leading to a general “exnovation” or scaling back of many common and expensive treatments such as coronary artery bypass graft surgery, carotid endarterectomy, coronary artery stenting, and inpatient back surgery.7 The ACA does support the growth of some new technologies that have uncertain benefits. For example, proton beam therapy for prostate cancer has diffused rapidly in recent years because of generous reimbursement by Medicare and private insurance.7 Medicare’s coverage generosity, especially for treatments that are physician-administered or given in an outpatient setting, influences coverage decisions made by commercial insurers and care delivered to patients in Medicare ACOs. This is especially true in the area of pharmaceuticals, where Medicare is pressured to pay for any cancer treatment in an approved compendium. Editorial