A few months ago, on March 23, the Affordable Care Act (ACA) turned 10 years old. Events to commemorate the anniversary were canceled at short notice, along with flights, classes, conferences, dinners, elective procedures, and most other aspects of daily life outside of the home. Much like the entire history of the ACA, just when you thought you could start to plan, the story took yet another turn. In addition to the fissures revealed by the coronavirus disease 2019 (COVID-19) pandemic, recent developments have included the advancement of the lawsuit to overturn the ACA completely1,2 and the narrow victory of Oklahoma’s ballot initiative to expand Medicaid. Still, the ACA endures, now providing a critical source of health insurance during the most dramatic loss of jobs the United States has ever seen.
Over the past 10 years, more than 20 million people have gained insurance coverage through the ACA who would not otherwise have been insured, most of these through Medicaid expansion. Now that more than 30 million claims for unemployment insurance have been filed, it is estimated that more than 25 million people could lose their insurance through job loss and about half of those may be eligible for Medicaid. States are working to provide those newly lacking jobs with coverage through health insurance exchanges and Medicaid, although options are more limited in nonexpansion states, where workers with low incomes and those with reduced work hours might fall into the coverage gap.
The outcomes of the ACA have been recorded in hundreds of JAMA Network articles (a search of JAMA Network revealed more than 2500 mentioning the ACA), including a piece written by former President Obama3 on the early benefits of the law. Buchmueller, Cliff, and Levy4 publish today in JAMA Health Forum about the positive outcomes of Medicaid expansion for those who enroll, health care professionals, and the economy as a whole. Additionally, within the past few months, there have been more than a dozen articles on topics, including reductions in health disparities,5 reductions in opioid-associated hospitalizations,6 and improvements in access to care.7
Nonetheless, the ACA is far from perfect, and the events of this year may provide impetus to fill remaining gaps. First, providing access to insurance does not necessarily make care accessible, nor does it necessarily make care equitable or affordable.8 Policies aiming explicitly to improve access to primary care, make access equitable, and bring down the costs of the basic health care services that provide entry to our complex health care system are sorely needed. Second, while access to insurance is not a panacea, it is a start. The coverage gap created by the US Supreme Court’s decision to allow states to expand at their own discretion could be remedied through a reenhanced match rate,9 which would have benefits for people who have low incomes and no jobs as well as for states during this recession. Further, a well-structured public option or change to the Medicare eligibility age could provide more affordable coverage in areas in which competition has not brought down insurance costs.10,11
Finally, more has to be done to actualize the ACA’s clear statement, since endorsed in multiple pieces of bipartisan legislation, that the health care system must move away from payment for volume towards payment for value. The use of fax machines to deliver nonstandardized reports to public health agencies during the COVID-19 pandemic is a vivid example of how little progress has been made in leveraging our public investment in electronic health records and in the authority of the Center for Medicare & Medicaid Innovation to improve health data and quality measurement. If we want debates on the best way to structure and finance our health care system to be based on data, and if we really aim to improve care access, quality, equity, cost, and ultimately value over the next decade, we must devote much more time, resources, and attention to measuring quality while holding all parts of our health care system accountable to improving it.
Correction: This article was corrected on July , 2020, to edit the phrase “could become lose” to “could lose” in the second paragraph.
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