Is Obamacare Working? Progress, but Obstacles Remain

By John Rother

As seen posted online by U.S. News & World Report

The Affordable Care Act was enacted nearly five years ago with the goal of addressing multiple dysfunctions in U.S. health insurance and health care delivery. Among the law’s aspirations was to make it possible for individuals with preexisting conditions to buy insurance coverage while simultaneously slowing the out-of-control growth in the costs of care. After less than a year in operation, and with several key provisions still not in effect, it’s clearly too early for any final evaluation. There are positive indications that progress is being made toward those aspirations, but major challenges lie ahead.

Millions of Americans have been able to obtain coverage who were previously uninsured, and competition among insurers seems to be robust in many, though not all, state marketplaces. Medicare’s drug benefit and coverage for preventative services has been substantially improved. New forms of health delivery, such as Accountable Care Organizations, promise to better coordinate care for those who have complex medical needs and generate the greatest costs. And driven in part by the signal the law’s cost-containment provisions sent to the health system, overall health care spending growth has substantially moderated.

Yet serious obstacles remain to health care access and affordability.

Most notably, roughly half of the states have so far chosen not to implement the Medicaid expansion. While state officials can debate the wisdom of the choice, it has created a “no coverage zone” afflicting vulnerable individuals and families with incomes too low for subsidized private coverage and too high for traditional Medicaid. By delaying access to necessary care and increasing the amount of unreimbursed care provided by doctors and hospitals, this coverage gap has the potential to increase costs.

Just as serious is the possibility that new cost-control initiatives might be weakened by the new Congress. Attacks on Medicare’s ability to test new payment and delivery models are particularly short-sighted in this regard, and could signal to the medical industry that cost restraint is no longer a priority. In addition, lifting mandate requirements for individuals and employers could compromise the ability of the insurance system to spread risk and keep premiums affordable.

Finally, failure to move forward in other areas of health policy could be damaging as well. If policymakers give up on efforts to permanently reform physician payment or otherwise slow the transition away from volume-based reimbursement, growth in health care costs could accelerate once more. And if pharmaceutical companies or other parts of the medical industrial economy fail to restrain prices for new drugs or devices, the very therapies we hope will improve outcomes will end up being out of reach for many Americans due to their exorbitant costs.

Can we do better than current law? We must. We must do more to deliver better care at a lower cost. We must find ways to make coverage more widespread and more affordable throughout the country. To be sure, there is much to be done to improve the U.S. health care system. But if we’re not careful, we could undermine those indications of progress that we’ve just started to see.

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