ACA at 5 Years: Standoff

An assessment of the ACA at 5 years would not be complete without acknowledging the effects of the law on the relationship between the American people and their government and the balance of power within our society.

David Blumenthal, MD, et al, “The Affordable Care Act at 5 years,” New England Journal of Medicine, June 18, 2015

As the July 4 Independence Day celebration approaches, it is time to admit the Patient Protection and Affordability Act (ACA) is a standoff between progressive and conservative elements in American society. For some, the ACA protects and makes care more affordable. For many, the opposite holds true.

Progressives can lay claim to successes: passage of the ACA, protection for those with pre-existing illnesses , insurance coverage of 16-17 million of the previously insured 2012 reelection of the President, and survival of two Supreme Court challenges.

Conservatives can point to the continuing unpopularity of the ACA, increased premiums and deductibles of many in the middle class, limiting of choice and individual freedoms, mandated financial penalties on individuals and businesses with slowing of the economy, and intrusions on the prerogatives of the states.

The result has been a standoff – the refusal of progressives to budge on the moral issue of greater coverage for all, and the insistence of conservatives that the ACA is anti-capitalistic and anti-choice. For the rest of President Obama’s term the ACA is “here to stay,” and after 2016, if Republicans win, the ACA may well be repealed or replaced by a market-based plan.

In the interim,

progressive strategies for reform – reducing Medicare hospital –acquired conditions and readmissions, paying for value for hospitals and physicians, bundling payments , ending or minimizing fee-for-service, and promoting accountable care organizations and transforming primary care into a team-based enterprise will be at play.


On the conservative side, Republicans will chip away at ACA funding, seek to end taxes on medical innovation companies. repeal the Independent Payment Advisory Board, and change the rules of the Employer Mandate by extending the period at which penalties for coverage kink in from 30 to 40 hours.


During this period, those enrolling in health exchanges and Medicare will increase, many millenials will prefer to pay penalties to not having a health plan, nearly half of the remaining 33 million uninsured will pay cash or barter for care, physician shortages (now 28,000 at the VA) will mount, more physicians will turn away those on Medicaid, Medicare, and health exchange plans, and ObamaCare-inspired high deductible plans will drive a consumer revolution towards direct cash, negotiated, competitive care.

The standoff will continue, at least after the 2016 elections and for indeterminate time thereafter. What may evolve is a two tier system, one paid, delivered, and run by government run, and the other in the private sector.