Millions Got Health Insurance, Questions of Cost Remain

Gail Wilensky is a senior fellow at  Project HOPE. She directed the Medicare and Medicaid programs from 1990 to 1992 and was a senior health and welfare adviser to President George H.W. Bush. Updated January 12, 2016, 3:22 AM

In health care, President Obama’s legacy is clear — the passage of the Affordable Care Act.

Of greater relevance to the Obama legacy is whether the A.C.A. has met its goals. Here the answer is less clear. The Affordable Care Act has multiple goals and has not been equally effective in meeting them. The clear win is the ability of people with pre-existing health conditions to become insured without discriminatory charges plus the latest government figures report the uninsured dropped to 33 million from 41.8 million — reflecting both the expansion of Medicaid and the availability of subsidized private insurance in the exchanges.

However, one of the reasons for the success in reducing uninsured — the extensive number of special enrollment periods — has also introduced undesired instability in the exchanges. Major insurers have reported special enrollment enrollees tend to be high cost and frequently drop coverage after their use of health care. This complicates future pricing and places a burden on future costs for spending and quality is still at other exchange users.

Passage of the Affordable Care is a huge success for Obama, but the legislation’s impact on best a work in progress.

The impact of the A.C.A. on health care spending is less clear. Questions about how much of the unusually slow increase in health care spending should be attributable to the health care law started almost as soon as the bill was signed. The debate focused on how much was attributable to the deep recession or might be “one-off” spending reductions versus reflecting the effects of the A.C.A. A  recent O.E.C.D. report suggests it was probably mostly the former. Health care spending per capita slowed drastically everywhere in the developed world between 2009 and 2014, and not just in the United States. We will have to see what happens to spending going forward as the economy begins to grow more robustly to understand the effects of the A.C.A. effects.

Improvements on quality and clinical appropriateness is also at best “a work in progress.” The A.C.A.’s accountable care organizations report more progress improving quality than in slowing spending. However, work on developing appropriate measures of value and quality to be used in measuring physician payment under Medicare is just beginning. Using the metrics to improve quality and appropriateness will need to follow from that.

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Gail Wilensky, Ph.D.