President Obama signed the Patient Protection and Affordable Care Act into law five years ago Monday, an anniversary that congressional Republicans will soon observe with another symbolic vote to repeal it. The general public isn't as eager to do away with the law, widely known as Obamacare, but surveys
— a view that hasn't shifted much over time. Meanwhile, the Supreme Court is considering a legal challenge that could render the law's landmark insurance reforms unsustainable in most states.
So it's not exactly a happy birthday for Obama's landmark legislative achievement. Despite the relentless attacks, however, the act has been a notable success on one front: It has helped millions of Americans obtain insurance coverage that would otherwise be out of their reach. By March, more than 21 million people had enrolled through new state insurance exchanges or
, including more than 16 million who'd previously been uninsured, and the number of Americans without coverage has dropped to a little over 12%,
. There's much more to be done to make healthcare affordable and sustainable, but lawmakers should build on the foundation laid by Obamacare instead of continuing to battle over whether to demolish it.
Critics called the act a government takeover of medicine, but it was hardly that. Instead, it used government healthcare programs as laboratories to seek improvements in cost control and quality that could be mimicked in the private sector. The law set tough new rules on insurers, but guaranteed them a huge influx of customers. It also gave states the chance to lead efforts to expand coverage and to reform their insurance markets, although partisan backlash against the law prompted many state legislatures to remain on the sidelines — or, worse, to try to undermine the law and discourage people from obtaining coverage.
Just how much the law has affected the healthcare industry is hard to say because the changes it sought were aligned with ones that were already happening. The rapid increase in premiums over the previous decade had already intensified the industry's search for payment systems and partnerships that could hold down costs, while also sparking mergers and acquisitions throughout the healthcare field.
The Affordable Care Act accelerated some of the shifts within the industry. It spurred the deployment of “accountable care organizations” and similar structures that gave doctors and hospitals financial incentives to keep patients healthy and treat them efficiently, rather than rewarding healthcare providers for giving the most expensive treatments to the sickest individuals. It increased penalties for wasteful or ineffective care in Medicare, while encouraging the industry to come up with more standards for measuring the quality of the treatments performed. One result, according to PricewaterhouseCoopers' Health Research Institute, has been a surge of new businesses into healthcare as entrepreneurs offer their own approaches to less costly, “consumer-oriented” care.
The act's most tangible effect, though, has been to eliminate some of the worst abuses that health insurers practiced on customers not covered by group policies, especially those with preexisting medical conditions. It pooled risks and costs broadly among individual policyholders in each state, the same way large group insurance plans do. Those reforms, combined with the new insurance subsidies and the expansion of Medicaid in
, have sharply reversed the years-long increase in the number of people who are uninsured.
At the same time, however, the expanded risk pools and comprehensive benefits mandated by the act have caused premiums to jump for many healthier Americans not covered by group plans. That rate shock exposed the law's weak point: It didn't do enough to control costs.
A key part of the effort to rein in healthcare costs is covering more people with insurance plans that promote wellness and prevention. The Affordable Care Act has done much of that work, so the rational thing for lawmakers to do now would be to build on that progress. But improving the act or even fixing its glitches has never been an option because the debate over Obamacare has always been political, not rational.