Obamacare 101: Promise, Pitfalls And Predictions

The scope, breadth and ambition of the Affordable Care Act (ACA) — whether you like the law or not — is unique in American history. It is our only example of comprehensive health reform at the federal level and it’s already forcing fundamental, even revolutionary, transformations in health care access, quality and cost control across the nation.

It is not perfect; virtually any section or provision of this law could have been better. Still, the ACA goes about as far as it was possible for Congress to go in the political environment of 2009 to 2010. And anything like it is inconceivable in our current political climate.

[sidebar title="About the Author" width="300" align="right"] John McDonough is a professor at the Harvard School of Public Health. From 2009 to 2010, he was a senior adviser to the U.S. Senate Committee on Health, Education, Labor, and Pensions. He is the author of the 2011 book, "Inside National Health Reform."[/sidebar]

Politically, the biggest challenges facing the ACA are behind us. By my count, the law has already survived three near-death experiences: the Democrats’ loss of a filibuster-proof Senate majority with the election of Scott Brown in Jan. 2010, the Supreme Court’s June 2012 decision upholding (with one exception) the law's constitutionality, and President Obama’s re-election last November. Much of what we see going on in Washington now is the death throes of the opposition, especially now that Americans are beginning to sign up for coverage.

When we reach Jan. 1, 2014, health access and private health insurance in the U.S. will never be the same. Though the ACA doesn't eliminate private health insurance, it fundamentally changes its structure and regulation. And many of those changes are already well underway.

Reforms already implemented allow children up to age 26 to remain on their parents’ health insurance, eliminate lifetime and annual benefit limits, regulate medical loss ratios, and close the Medicare Part D donut hole, along with many other things. If the ACA accomplished only these reforms, it would still be highly significant legislation, and this is just the beginning.

Much of what we see going on in Washington now is the death throes of the opposition, especially now that Americans are beginning to sign up for coverage.

The biggest changes will transform people’s ability to buy health insurance. An insurance concept known as “guaranteed issue," set to take effect on the first of the year, bans the practice of “medical underwriting” and the imposition of pre-existing condition exclusions. The individual responsibility provision, called the individual mandate, will impose a new tax penalty on individuals who do not buy health insurance and who can afford to do so. A new set of tax subsidies will make health insurance affordable for many uninsured Americans. And consumers in every state will be able to purchase coverage through exchanges or market places — some run by states and some by the federal government.

We have a working example of an exchange in Massachusetts called the Health Connector. It works like an Expedia or Travelocity for health insurance. A few years back, my son returned to Massachusetts and needed to buy health insurance. We went on the Health Connector website, compared options, and bought him a policy — soup to nuts — in about 15 minutes. As of Oct. 1, that is now possible for almost all Americans.

As written by Congress, the ACA guarantees all low-income Americans — those with incomes up to 138 percent of the federal poverty level — the right to enroll in their state's Medicaid program. In June 2012, the U.S. Supreme Court ruled that the states had the option not to participate in the ACA’s Medicaid expansion of benefits for those with incomes up to 400 percent of the federal poverty level.

During the legislative process and afterwards, architects of the ACA were accused of implementing health care rationing. It was never true. But, ironically, the Court-amended version of the ACA includes the most insidious form of rationing imaginable: Beginning on Jan. 1, the only people without guaranteed access will be low-income Americans and legal immigrants in states that refuse to expand Medicaid.

My expectation is that once the ACA is successfully and fully implemented early next year, most opposition will melt away. Beginning in 2015, Congress will resume its customary and necessary role of providing vigorous oversight and reforms to the ACA.

By 2020, I believe that most states will have expanded Medicaid to cover most of their low-income residents. And the reforms embedded in the ACA that aim to lower costs and improve the quality, efficiency and effectiveness of care will grow stronger and deeper.

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