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President Obama outlines progress, future of Affordable Care Act

The United States "will be better off" due to the progress that the Affordable Care Act has made in addressing inadequacies in the health care system, according to a special communication issued by President Barack Obama, JD.

Published in JAMA, President Obama also urged future policy makers to continue this progress in order for the country to realize its maximum benefits.

"When I took office, health care costs had risen rapidly for decades, and tens of millions of Americans were uninsured," he wrote. "...The Affordable Care Act (ACA), has made substantial progress in addressing these challenges. Americans can now count on access to health coverage throughout their lives, and the federal government has an array of tools to bring the rise of health care costs under control. However, the work toward a high-quality, affordable, accessible health care system is not over."

Barack Obama

The President evaluated overall progress between 1963 and early 2016 and how to continue that progress in the future using research findings and data from government agencies. He also shared his experiences in changing health and public policy.

Obama reported that the rate of uninsured Americans declined by 43%, from 16% in 2010 to 9.1% in 2015; much of that decrease occurred after the ACA took effect. The number of uninsured Americans decreased from 49 million in 2010 to 29 million in 2015, marking the largest decrease since Medicare and Medicaid were created.

In addition, research has identified improvements in health, treatment and financial security for those who have enrolled. For Americans who were already insured, research has shown improved coverage, including maternity care, preventive services and mental health care.

Obama also noted that the ACA has reformed the health care delivery system, particularly in terms of payment.

Approximately 30% of traditional Medicare payments currently move through alternative payment models, such as accountable care organizations and bundled payments, compared to virtually 0% in 2010.

The reforms have led to "a sustained period of slow growth in per-enrollee health care spending," as well as lower-than-expected health care spending in general and health care quality improvements.

"Despite this progress, too many Americans still strain to pay for their physician visits and prescriptions, cover their deductibles, or pay their monthly insurance bills; struggle to navigate a complex, sometimes bewildering system; and remain uninsured," Obama said.

He called for more work to reform the system, and offered some suggestions, including flexibility with adjustments as the most recent reforms have not reached their full effects, more financial assistance to help Americans who are unable to afford coverage, enhanced competition in the Marketplaces and legislative action regarding prescription drug costs.

Obama had an additional suggestion for Congress.

"There is another important role for Congress: it should avoid moving backward on health reform," he said. "While I have always been interested in improving the law — and signed 19 bills that do just that — my administration has spent considerable time in the last several years opposing more than 60 attempts to repeal parts or all of the ACA, time that could have been better spent working to improve our health care system and the economy."

Obama also shared lessons that he has learned throughout the ACA process, noting that he has "put them into practice in both health care policy and other areas of public policy throughout my presidency."

He noted the difficulty of change in general and stressed the need for cooperation instead of obstruction; that special interests, such as the pharmaceutical industry, are a threat to change; and that pragmatism is essential and benefits are typically greatest when common ground is found.

The President acknowledged that his lessons may feel discouraging, he is optimistic about the country and its "capacity to make meaningful progress on even the biggest public policy changes."

"I will repeat what I said 4 years ago when the Supreme Court upheld the ACA: I am as confident as ever that looking back 20 years from now, the nation will be better off because of having the courage to pass this law and persevere," Obama concluded. "As this progress with health care reform in the United States demonstrates, faith in responsibility, belief in opportunity, and ability to unite around common values are what makes this nation great."

Howard Bauchner , MD, editor in chief of JAMA, wrote in an accompanying editorial that authors of three additional editorials agree that the ACA has fulfilled its primary goal of providing more Americans with health insurance.

"There is less agreement on the cost of health care, with differences of opinion emerging about the increase in health care cost in Medicaid and Medicare vs. private insurance, and whether the apparent slowing of the increase in health care costs in Medicaid and Medicare is attributable to the ACA or to the recent economic recession," Bauchner wrote. "Given the many remarkable advances in health care and the cost associated with them, it may never be possible to understand the effect of the ACA on cost, particularly as more time passes since the enactment of the ACA."

Peter Orszag, PhD, former director of the Office of Management and Budget under President Obama, wrote that "fundamentally, the ACA is working," and outlined several surprises that have arisen since the ACA took effect.

They included a decrease in health care costs, improvement in the quality of health care, resiliency in employer-sponsored plans and a substantial increase in Medicare Advantage Enrollment.

"The US health care reform glass is more than half full," Orszag concluded. "Despite ongoing and legitimate concerns about the public exchanges, the ACA has proven remarkably successful at boosting coverage and reforming the delivery system."

Stuart M. Butler, PhD, MA, a senior fellow in economic studies at the Brookings Institution and former director of the Center for Policy Innovation at The Heritage Foundation, shared a list of aspects of the ACA that need to be revamped.

He said that subsidies should be changed so that they are easier to understand and make coverage more affordable; the tax exclusion for employees with employer-sponsored insurance should be replaced with a refundable tax credit; the Independent Payment Advisory Board should be replaced with a "premium support system" for Medicare; and the ACA should also be seen as a program that promotes health. He also called for increased federalism within the health care system and flexibility for private plans.

"It is both pragmatic and principled to recognize that achieving agreement on how to redesign an economy that large, or to do it successfully in one piece of legislation, is beyond the capabilities of the federal government," Butler wrote. "That is why core parts of the ACA need to be reassessed and revised and why empowering the US system of federalism to adapt and experiment with the law is so important."

Jonathan Skinner, PhD, the James O. Freedman Presidential Professor of Economics at Dartmouth, and Amitabh Chandra, PhD, Malcolm Wiener Professor of Social Policy at the Harvard Kennedy School of Government, wrote that the President should be pleased with what the ACA has accomplished.

"The nation is better off with the ACA, despite its shortcomings, than without," they said. "But health insurance, health care, and health, although often used interchangeably, are not the same. Even though the ACA has, to this point, not accomplished its goal of making health care more affordable, it is also far more moderate, innovative — and difficult to replace — than its critics claim." – by Chelsea Frajerman Pardes

Additional references:

Bauchner H. JAMA. 2016;doi:10.1001/jama.2016.9872.

Butler SM. JAMA. 2016;doi:10.1001/jama.2016.9881.

Orszag PR. JAMA. 2016;doi:10.1001/jama.2016.9876.

Skinner J, Chandra A. JAMA. 2016;doi:10.1001/jama.2016.10158.

Disclosures: Butler reports no relevant financial disclosures. Chandra reports serving on the Panel of Health Advisors for the Congressional Budget Office; consulting for Precision Health Economics; and receiving personal fees from Biogen, Vertex, Pharmaceutical Care Management Association, and Novo Nordisk. Orszag served as the director of the Office of Management and Budget under President Obama and has also served as the director of the Congressional Budget Office. Skinner reports being an investor in Dorsata and an unpaid member of the Altarum Institute's National Advisory Committee. Please see the full study for President Obama's public financial disclosure report for 2015.