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In a Special Communication in this issue of JAMA, US President Barack Obama presents a summary of the Affordable Care Act (ACA), describing the successes, the challenges ahead, and the policy implications of the legislative history of the ACA.1 Three other editorials accompany the article.2-4 Peter Orszag, former director of the Office of Management and Budget under President Obama; Stuart Butler, a senior fellow in economic studies at the Brookings Institution and former director of the Center for Policy Innovation at The Heritage Foundation; and coauthors Jonathan Skinner, the James O. Freedman Presidential Professor of Economics at Dartmouth and Amitabh Chandra, Malcolm Wiener Professor of Social Policy at the Harvard Kennedy School of Government, each reflect on the Special Communication and provide scholarly insights about the ACA and current health policy. They also discuss the important next steps for US health care. In the past 2 years JAMA has published numerous articles about the ACA, including several that have been critical of the law and have outlined needed changes.5-12
There is agreement among the president and authors of the 3 editorials that the ACA has accomplished one of its primary goals: approximately 20 million individuals have gained 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. 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.
In his article President Obama details the progress related to the ACA—the decline in the number of uninsured, the blunting of the increase of health care costs in Medicaid and Medicare, and the overall improvement in access to care and other processes of care. Although the president outlines numerous future challenges, such as further expansion of Medicaid, controlling the increase in drug prices, and the need for greater competition in certain health care markets, he does not specifically directly address the 20 million to 25 million individuals who remain uninsured or the increase in health care costs in the private sector. However, there will never be a randomized clinical trial of health care expansion in the United States; only observational data will be available. Accordingly, while some will dispute the findings and extent of progress described by the president, ultimately the data are critical and speak extremely well of the early years of the ACA.
Has there been true improvement in the health of the nation and in individual health outcomes following enactment of the ACA? To date, robust, high-quality data clearly demonstrating substantial improvements in health outcomes directly related to the ACA have not been reported. While access to care has improved and readmission rates for some diagnoses have declined, these are not true health outcomes, but rather reflect measures of processes of care. It takes years to influence the health of an individual and even longer to improve the health of a population, so it would be unfair to expect that the ACA, in a matter of only a few years, would improve true health outcomes of individuals, much less that of the nation. In addition, social determinants of health, which are generally outside the remit of the health care system, influence the overall health of a population more than health care itself.13-16 The great gains related to the ACA—if they are to be realized—are in the future.
JAMA is pleased to publish this Special Communication from President Barack Obama, as he writes “The Affordable Care Act is the most important health care legislation enacted in the United States since the creation of Medicaid and Medicare in 1965.” We hope that the US presidential candidates will consider submitting to JAMA their ideas about further health care reform before the 2016 election, and we welcome any future president to submit to JAMA any article about major health care initiatives.
Corresponding Author: Howard Bauchner, MD, JAMA, 330 N Wabash Ave, Chicago, IL 60611 (firstname.lastname@example.org).
Published Online: July 11, 2016. doi:10.1001/jama.2016.9872.
Bauchner H. The Affordable Care Act and the Future of US Health Care. JAMA. 2016;316(5):492–493. doi:10.1001/jama.2016.9872
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