How is the Affordable Care Act doing?

By Michael Hochman, MD, MPH and Pieter Cohen, MD (follow us at @slowmedupdates or on the web.)

As the Affordable Care Act (ACA) enters its third active year, we’re taking a look at an interesting summary of its benefits and barriers to health care so far that was recently published in The New England Journal of Medicine.

In this paper, Dr. Benjamin Sommers, assistant professor of health policy and economics at the Harvard T.H. Chan School of Public Health, explains that the number of uninsured individuals in the United States has fallen from roughly 50 million in 2010 to between 30 and 34 million as of 2015.

This coverage expansion has resulted in modest improvements in access to primary care and medications, the affordability of care, and self-reported health. (See the graph in this recent original research paper from Dr. Sommers.)

Yet despite the successes so far, approximately 30 million Americans remain uninsured for a variety of reasons, including:

• 3 to 4 million Americans live in states that have opted not to expand Medicaid
• about 5 million U.S. residents do not qualify for ACA coverage options because they are undocumented.

In addition, many people who would qualify for subsidies through the exchanges have not signed up for coverage despite the mandate to do so. Why? Mostly because they are not aware of the options, or because it is still cheaper to take the tax penalties than to buy insurance.

For those who have received coverage through the ACA, two main barriers limit access to primary care. The first is the burden of cost sharing. For instance, Deductibles often range from $3,000 to $5,000. And according to a recent NY Times and Kaiser Family Foundation poll, about 20% of individuals who have insurance still struggle to pay their medical bills. Second, provider networks are narrow. Reports suggest that some plans even exclude certain specialties, particularly endocrinology, rheumatology, and psychiatry according to one recent analysis.

Looking toward the future of the ACA

We are encouraged that increasing numbers of people now have health insurance, though it is a far cry from the 30 million newly insured Americans that many advocates had predicted.  And while health care costs have been growing more slowly than before the ACA, it isn’t clear if that’s been the result of the ACA itself or the general economic downturn. Even though the improvements in patient-reported access and overall health have been modest thus far, the ACA deserves a few more years before we draw firm conclusions.

That said, we suspect that the ACA will prove little more than a temporary Band-Aid for our ailing health care system. We seem to be rearranging deck chairs on the Titanic. In our opinion, the most systematic and equitable approach to expanding coverage and access would be a comprehensive, national health care program.

But perhaps more important: regardless of how we expand coverage, we must keep our sights on the ultimate goals. Beyond increasing coverage or even access to primary care, we need to provide high-quality, comprehensive, accessible, and patient-centered care to everyone. And that will take a culture shift in how we provide care, not just insurance coverage.