ACA's Fourth Birthday: A Good Reason to Celebrate

The "Patient Protection and Affordable Care Act" is now four years old and March 31 brings to a close the first major enrollment period of our nation's health reform law. And there is good reason to celebrate.
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The "Patient Protection and Affordable Care Act" is now four years old and March 31 brings to a close the first major enrollment period of our nation's health reform law. And there is good reason to celebrate.

Numerous provisions such as the insurance reforms, rollout of community-based preventive health services and expansion of coverage to young adults on their parents' policies have been implemented seamlessly. Others such as the enrollment in some of the exchanges have had a rocky start. Nevertheless, the scorecard is in and 18 million people now have quality, more affordable health insurance coverage. In addition health care costs are down for individuals, families, businesses and the government. The system is decidedly moving toward a culture that promotes prevention and wellness as a first option, and the early returns show improvement in processes of care that correlate with better health outcomes as well as some early indicators of improved health.

The expansion includes 3 million young adults who have stayed on their parents' insurance, 6 million individuals in the health exchanges and 9 million in Medicaid and the State Children's Health Insurance Program. This is a momentous event that defies all of the misguided and sometimes vicious efforts to keep people from enrolling. The exchanges are up and running with the size, scope and age mix that will work. Concerns about widespread adverse risk selection and unaffordability have shown to be wrong.

Medicaid enrollment has also expanded dramatically nationwide despite the Supreme Court's ruling and the reluctance of several state policymakers to support expansion. The 9 million people who have signed up for Medicaid coverage and SCHIP coverage include both expansion states and non-expansion states. The increase in coverage in the non-expansion states is due to the so-called "woodwork effect." This reflects the people who are eligible but not enrolled under the existing Medicaid and SCHIP programs who seek coverage as they hear about the ACA and find out they are already eligible for coverage under existing state authority. While it remains to be seen exactly how many of these people are entirely new to the ranks of the insured, it is probably a moot point since the March 10 Gallup poll shows a dramatic drop in the number of uninsured Americans from 18 to 15.9 percent. This number is likely to continue to drop over the summer because, unlike the coverage in the health exchanges, Medicaid enrollment does not have an open enrollment period and will continue year round. This is especially important for the neediest populations.

So on its fourth birthday, let us look at the measures of success. On March 23, 2010, when the ACA was signed into law, there were approximately 50 million uninsured people in America. The law was originally designed to cover 32 million people -- 16 million under the exchanges and 16 million in Medicaid and SCHIP. The U.S. Supreme Court threw a monkey wrench into the law by allowing states to opt out of Medicaid coverage reducing the exchange projection by 3 million. Because of the challenged technology rollout of the exchanges the Congressional Budget Office adjusted its estimate of the exchange enrollment to 7 million in the first year. The White House just announced that over 6 million Americans have signed on, which is a pretty good outcome considering all of the barriers put in the way.

Now after four years it is time to recommit ourselves to this important public health effort because we are winning. Early evidence is showing that the cost curve is bending, access is up and quality is improving. For example we are making progress on health care-associated infections and communities are addressing other winnable battles thanks to the ACA's Prevention and Public Health Fund and other investments in public health.

While we have a way to go, this has been a good fourth birthday and a real reason for celebration.

Georges C. Benjamin, MD, is executive director of the American Public Health Association.

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