The Affordable Care Act is 15 years old!

Oy.

On March 23, Heather Cox Richardson celebrated the 15-year anniversary of the Affordable Care Act (ACA) also known as Obamacare in her Letters from an American newsletter. I was surprised that when I sent the article to a few friends, commenting that 40 million additional Americans had health insurance thanks to the ACA, that there was lots of negative commentary from doctors I know who are active in medical issues. They pointed out that the cost of medical care has skyrocketed since 2010. They questioned affordability of health insurance under the act and complained that it having insurance did not guarantee good care. What good is insurance if you can’t see your doctor in a private practice anymore but had to see a Nurse Practitioner or a PA in a hospital-based practice?

I had simply pointed out that more Americans had health insurance because of the ACA and that some insurance was better than none, but the pushback I received made me question my basic assumptions. Did the ACA help people get insurance, improve access to health care, improve the quality of care or the business of health care or did it cause more problems? It turns out that this is not a simple question to answer.

The health care system in the United States is incredibly expensive and complicated, as I have pointed out before. Attempts to reform the system care go back decades, with three landmark legislative victories for the reformers; the passage of Medicaid and Medicare under Lyndon Johnson in 1965 and the Affordable Care Act under Obama in 2010.

The ACA was a huge bill, with over 2500 pages. Thousands of regulations and dozens of new regulating boards and commissions have been created as a result. The bill not only promised insurance for more Americans, it promoted alternative payment methods for Medicare and Medicaid, created federal support for electronic medical records and health information exchanges, and promised to improve access to care and health care quality. It was a huge bill with multiple moving parts.

The ACA was the result of concerns about millions of Americans who lacked access to health insurance as the cost of care continued to skyrocket. People were afraid to leave their jobs and lose their insurance coverage even as that coverage became increasingly unaffordable. Hospitals and doctors had to deal with millions of dollars in uncompensated care. Medical bankruptcies topped the list of unpaid debt. Everyone agreed that there was a need, but the ACA was passed by Congress with only Democrat support and using of some complex legislative maneuvering. It has remained controversial, though opponents have struggled to find a viable alternative. President Trump notably commented that he would figure it out after the ACA was repealed. It was apparent that he had no plan.

One problem with the ACA is that most individuals who have gained coverage gained that coverage through Medicaid. Medicaid is not a robust insurance option. I would certainly not choose it for myself. For those who receive subsidies to join the state health insurance exchanges, premiums are affordable, but deductibles and administrative hassles are high. Among those earning more than 400% of the poverty limit, who do not qualify for subsidies, exchange insurance programs are often unaffordable. Some states did not accept Federal money to expand Medicaid thus denying insurance to millions. At first, I thought that this was insensitive and counterproductive, but there are downsides to increasing Medicaid coverage.

If working individuals qualify for Medicaid, or for subsidies under the ACA, and they no longer participate in their employer coverage, the employer will have fewer covered lives in their health plans and premiums could go up. This is exactly what has happened in New York State. Also, because healthy, young people have not signed up for ACA benefits (remember the fight in court over mandates for young people to participate?), the insurance plans are filled with older and sicker individuals, making the insurance program unsustainable.

As I already mentioned this is complicated stuff, and I have only scratched the surface. The ACA was also designed to control overall health care costs and raise quality of care, but costs have continued to rise, and quality has not been shown to improve. The ACA required HSS to experiment with alternative payment models, which it has done. With the proliferation of additional insurance plans and programs to reward quality of care, including managed Medicaid, Medicare Advantage plans and incentive plans for physicians, health care insurance coverage has only become more expensive and confusing for patients and providers. One program designed to give doctors incentive to improve quality of care ended up penalizing more doctors who failed in reaching HSS targets than it rewarded for participating.

An additional aspect of the ACA was the promotion of Electronic Medical Records (EMRs). While EMRs have been widely adopted, in part due to financial incentives for physicians to obtain and use them, the overall effect of the EMR has been a slow-moving disaster for physicians with little benefit to patients. Efficiency in medical practice has decreased, in part due to the EMR.

After reviewing articles in academic and business journals about the ACA, I must conclude that it has not had a net positive effect on health care in the United States. While more people do have insurance, that insurance is of poor quality, or expensive. Federal efforts to improve quality of care and reduce overall costs have mostly failed, and efficiency has suffered as doctors struggle to deal with a confusion of insurance plans and poorly designed electronic medical records. To deal with all the complexity doctors have been driven to join larger groups or to sell out to large investors, all of which has pushed prices and costs higher, and decreased personal aspects of care.

There are two things which have not happened that could improve quality and cost. First, there needs to be increase reimbursement for primary care, attracting the best and the brightest to become Family docs, Internists, Pediatricians and OB/GYNs, not superspecialists. Second, the government should create national templates for insurance plans and coverage to reduce variation in the insurance industry. Let insurers really compete on the basis of quality – the quality of their service and the robustness of their physician panels.

Unfortunately, there is little likelihood that congress will make any improvements to the health care marketplace any time soon. Americans suffer in a health care system that is costly and inefficient, a system which rewards those doing special procedures and ignores primary care, a system which despite the huge cost, does not improve the health of Americans when compared to other industrialized countries.

The Affordable Care Act was an attempt to move this huge and ungainly system in the direction of improvement in cost and quality, but I am afraid that it has failed. Fixes are needed, but unlikely to appear any time soon.

Breaking News:

In case you hear it and get confused, part of RFK, Jr.’s efforts at HHS includes cancelling at least 2 experimental payment methods for primary care services. In my opinion, this is a good thing. RFK’s support for primary care is a breath of fresh air in a system dominated by high cost specialty care. These experimental programs under Medicare add complexity to primary care without increasing reimbursement for the doctors or increasing quality of care for participants. I look forward, hopefully. Will HSS and Medicare finally recognize the value of primary care and pay for it? One can only hope.

Jef Sneider, MD

Syracuse, NY

April 2025