Assessing the ACA in the Political Fog

By Steffie Woolhandler, M.D., M.P.H., Adam Gaffney, M.D., and David Himmelstein, M.D.
MedPage Today, Aug. 26, 2016

In the current overheated political climate, the Affordable Care Act (ACA) has garnered harsh criticism from some quarters and extravagant praise from others. Both miss the mark.

Critics from the political right seem to ignore the fact that the law has substantially reduced the number of uninsured, and propose alternatives that would sharply increase uninsurance, underinsurance, and healthcare inequality.

On the other hand, President Obama's recent defense of the ACA in the Journal of the American Medical Association papered over its flaws -- notably the fact that 29 million remain uninsured, a figure that the Congressional Budget Office predicts will not change much in the years ahead, even if all states were to accept the ACA's Medicaid expansion.

While persistent uninsurance is the ACA's most glaring deficiency, it has other shortcomings: failure to slow the hollowing out of already inadequate coverage; further stimulation of the already overgrown healthcare bureaucracy; lack of effective cost controls; and Medicare payment reforms that tilt the playing field towards giant corporate organizations and have triggered a surge of mergers and acquisitions.

There can be no doubt that the ACA improved both coverage and access to care. The number of uninsured has fallen by 41%, with the largest gains among the poor, near-poor, and minorities. The percentage of Americans unable to afford medications or needed care has also fallen, although more modestly.

Yet post-ACA, more than a quarter of poor non-elderly adults remains uninsured. Moreover, high out-of-pocket costs continue to deter many of those with coverage from seeking care when they need it.

Unfortunately, many of those who received insurance under the ACA simply cannot afford to use it. ...