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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Imagining an Alternate Timeline for the ACA

About 2 weeks ago, on March 23, we hit the eighth anniversary of the Affordable Care Act (ACA). Even as I marvel over the many positive changes in our country over the last 8 years, I can’t help but wonder what might have been had the country aligned together to implement the law rather than turn it into the political football it has been.

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The positive changes are as easy to spot as they are often taken for granted. Many individuals can now change jobs or start companies without worrying about losing access to health care. Many no longer need to ignore illnesses for fear that they will not qualify for insurance for the rest of their lives. Gone are the days of long insurance questionnaires and fine-print “gotcha” insurance policies that don’t cover people when they get sick. Lifetime caps, which used to routinely haunt those with the bad luck to have a major illness or be born prematurely, are now illegal—as is not covering mental health, maternity, and other basic care. Meanwhile, millions now have guaranteed access to free preventive care.

Even as many of those changes are under threat, what is known about the outcomes from the ACA so far is strikingly good. Medical debt is down, improving families’ access to credit. Uncompensated care has been reduced, and rural hospitals are doing better. Fewer people are skipping needed medical care due to cost, more have a regular source of care, and more people with chronic conditions are getting regular care for them. In places like Louisiana, which tracks the outcomes publicly, more women are getting mammograms and having cancer diagnosed at early stages, preventing expensive and avoidable misery. With better preventive care, people are getting treatment earlier in the course of their disease. In addition, according to an analysis by Benjamin D. Sommers, MD, PhD, Atul A. Gawande, MD, MPH, and Katherine Baicker, PhD, of the Harvard T.H. Chan School of Public Health, recent research indicates that the health benefits of having a regular source of care are just beginning to show up.

Yet I can’t help but wonder what might have been if, after the ACA’s passage in 2010, both parties had gotten together and embraced the goal of getting more people access to affordable care and improving the law instead of what actually happened—a sustained assault on the law from Republicans.

  • What if Congress hadn’t stripped out money targeted for rate stabilization, and instead embraced the goal of greater competition to bring down costs?

  • What if all the states had embraced Medicaid expansion rather than turning away federal dollars to insure state residents who are most in need?

  • What if all states had operated their own exchanges and actively reached out to and enrolled their residents, as Kentucky and other states did?

  • What if over the last 8 years we had embraced the challenge of the lack of competition in rural communities rather than view it, as ACA opponents did, as an issue to be exploited?

  • What if we had seized the opportunity to improve affordability for the middle class by extending subsidies, given that ACA was under budget estimates?

  • What if the Trump administration and Congress hadn’t spent the last year pressing for ACA repeal, sabotaging the single risk pool, and calling the ACA “dead,” but instead had focused on drawing in insurers and protecting more people and protecting them with high-quality coverage?

In other words, what if Congress had acted with the decency and humanity to implement the law the best we could and work in good faith to fix what needed fixing?

Sadly, the implication of the “what ifs” are all too clear. Health insurance would cost a lot less, there would more competitors, and millions more would have insurance and the improved outcomes that go with them.

The law also would likely be different in ways that cannot be predicted. With even minimal cooperation, a wider variety of ideas, including more conservative ones, could have made their way into the law as lawmakers compromised on subsequent legislation. Without a constant existential repeal threat, Democrats would have been more open to trying out different ideas.

Laws are always going to have flaws. In the omnibus law passed in March, Democrats joined Republicans in fixing a problem in the recent tax bill that negatively affected farmers. But for most of the past 8 years, Republicans have so vehemently opposed making any fixes to the ACA that minor legislative improvements were never considered. The text of the law remains the text—even as it becomes outdated. Even minor drafting errors were turned into court cases to dismantle the law.

The implications of this partisanship are real in ways big and small. As members of the Obama administration, my colleagues and I could have conversations with members of Congress on both sides of the aisle about opportunities to improve the Medicare program, with confidence that we could work on the issues despite our differences. Not so for the ACA, when every chance to improve the law was taken as an opportunity to call for its repeal. A legislative process that prevents us from learning and making changes to the law is an enormous hurdle for policy makers who seek to make it work better for the public.

Eight years after the ACA’s passage, the United States could be dramatically further on the path to a better health care system. Instead, the country can no longer take for granted the national commitment to implementing our laws for the best interests of the country. No new policy, no matter how good, will work as intended upon passage. It’s not our ideas that need to be improved the most, it’s our politics. Health care is a victim of the forces that make, for politicians, polarization more profitable than progress.

The public, by large margins, wants Congress to focus on improvements to our health care laws, not obstruction. Eight years into the ACA and decades into the battle for a more equitable health care system, our politics are failing us. The path to progress now depends on whether the public can drive home that message to our politicians.

About the author: Andy Slavitt, MBA, served as the Acting Administrator for the Centers for Medicare & Medicaid Services under President Obama from 2015 to 2017, where he focused on advances in health care coverage and accelerating health care delivery system transformation. He has 2 decades of private–sector health care leadership, both as a senior executive at Optum, a health services and innovation company, and as an entrepreneur. He tweets at @aslavitt. (Image: US Department of Health and Human Services)
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