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August 2, 2016

The Past and Future of the Affordable Care Act

Author Affiliations
  • 1Department of Economics, Dartmouth College, Hanover, New Hampshire
  • 2Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
  • 3John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts
JAMA. 2016;316(5):497-499. doi:10.1001/jama.2016.10158

In this issue of JAMA, President Barack Obama has provided a comprehensive assessment of the Affordable Care Act (ACA),1 which as he indicates is the most comprehensive health care reform since Medicare. In 1965, Medicare passed in the House with a 313-115 vote and in the Senate with a 68-21 vote. By contrast, the ACA barely reached the filibuster-proof threshold of 60 votes in the Senate and passed the House with a 219-212 vote. As President Obama has chronicled, that the ACA passed at all, let alone survived multiple Supreme Court and Congressional challenges, is a political miracle.

Despite these compromises and partial setbacks, the primary goal of the ACA has been met: to expand the number of people with health insurance. With an estimated expansion in health insurance of 20 million individuals, President Obama is right to claim credit for the ACA. But counting up the number of individuals with insurance is not enough to assess if the ACA was a success. Perhaps the more important measures are whether the ACA improved health and saved money. For example, the 2008 Oregon Health Insurance Experiment, a randomized trial of Medicaid expansion, found that newly insured individuals used more hospital care, were given more prescription drugs, and received more preventive care than before receiving insurance. Individuals were less likely to be diagnosed with depression and experienced less medical debt, a leading source of bankruptcy. Although almost everyone reported being able to see a physician, hypertension and diabetes control did not change relative to the control group, overall medical spending increased by $1000 per person annually, and emergency department use increased by 40%.2,3