ACA: A Retrospective Three Years On
“We have to pass the bill so you can find out what is in it. – House Speaker Nancy Pelosi, March 9, 2010.”
It was one of the most notorious quotes that emerged from the battle over the Affordable Care Act.
The line was taken out of context, as Pelosi’s office has continued to protest. But more than three years after her quote Pelosi’s accidental gaffe seems pretty apropos.
Three years after its passage, the law continues to delight supporters with what they see as positive surprises. For example, some backers say the ACA deserves credit for the unexpected slowdown in national health spending. But critics warn that the law’s perverse effects on premiums are just beginning to be felt.
What The Law Got Right
It expanded health coverage — and maybe more than you think. While many observers tend to focus on the coverage provisions that take effect next year, several experts noted that the ACA’s increasing access to insurance have been near immediate.
“We already have hundreds of thousands of Californians now covered under new options that didn’t exist before the Affordable Care Act, from PCIP to LIHPs to the young adults on their parents’ coverage,” according to Anthony Wright, the executive director of Health Access.
Millions of patients now get no-cost preventive care. The number of patients receiving free services like a mammogram, flu shot or annual wellness visit “has dramatically expanded,” noted Timothy Jost, a law professor at Washington & Lee.
Providers are innovating on care delivery. The ACA contains direct funding for Medicare accountable care organizations and other coordinated-care efforts, but the trickle-down effects beyond government-led reforms have been incredibly positive, experts say.
Mental health services received a huge boost. The law “is the most important change to [mental health/substance abuse] policies in many years,” said Harold Pollack, a public policy professor at the University of Chicago.
The model of risk selection. The law deserves credit for eliminating health status underwriting and denying coverage for pre-existing conditions, Jost noted.
What The Law Got Wrong
It’s written in a very confusing way. Overwhelmingly, experts pointed to the challenges that emerged from the rushed process to finalize the bill — confusing statues and loopholes that are still making trouble for regulators.
Implementation took way too long. Even Don Berwick, M.D., the former head of CMS, thinks that the ACA’s staggered implementation is regrettable.
It passed the buck to get necessary bucks. The Affordable Care Act's efforts to raise revenue “were very bad,” argued Josh Barro, lead writer of Bloomberg View's blog The Ticker, with complicated tax provisions and too much pressure on high earners.
And there’s a deeper issue behind the law’s structure, suggested Barro.
“It’s pernicious to tell people that we’re going to expand the size of the federal government, and don’t worry — someone else is going to pay for it,” he said.
It included too much complexity for businesses.
Many employers are still puzzling over how the ACA will affect their operations and trying to figure out whether they’ll keep or drop health coverage when new provisions begin to take effect next year.
It opened the door to provider collusion. Berwick noted that the ACA’s push to integrate care also set up an opportunity for providers to take advantage of the law for their own benefit: By using their expanded market power to push for higher prices. Perhaps the law could have been better structured to protect against that outcome, he suggests
Looking At The Next Three Years - And Beyond
While President Obama’s re-election cinched the ACA’s survival, a tremendous amount of effort still lies ahead to ensure that the law reaches its potential.
But it’s important not to be too hard on the ACA, Pollack warned.
“It’s miraculous that the bill passed at all, given all the obstacles,” he said.
Dan Diamond is a columnist for CaliforniaHealthline, where a longer version of this op-ed originally appeared.
