For President Obama's last full day in office, the Daily Briefing's Josh Zeitlin asked several health care experts, "How would you describe how President Obama changed health care? What do you think he got right on health care, and how do you think he erred?"
Jump to a sectionAshish Jha
Below are their responses, which have been edited and condensed for clarity. On Monday, we'll share how the same experts expect President-elect Trump to change health care.
Internal medicine physician, VA Boston Healthcare System; health policy professor, Harvard T.H. Chan School of Public Health; director, Harvard Global Health Institute
The massive improvement in reducing the uninsured is a very important accomplishment unto itself. However you feel about the way it happened and how much it cost, the truth is that 20 million Americans probably have health insurance that they wouldn't have had otherwise.
A corollary to that, which may be an even bigger accomplishment in some ways, is that the Affordable Care Act has kind of embedded in the minds of a majority of Americans that everybody should have access to health insurance. If you listen to the repeal and replace conversations, they all are increasingly saying, "We'll cover as many people as Obamacare." The notion that you have to cover people is not a classic Republican idea. The classic Republican idea is that health insurance is individual responsibility, and people have to figure it out on their own. I think Obamacare has changed the conversation, where a majority of Republicans now believe it's the responsibility of government to make sure that people get access to health care.
“Did the ACA appreciably make quality better? I would say it's not really clear.”
Harvard professor Ashish Jha
The Obama administration has also put a lot of attention on the cost problems and quality problems facing health care. They've experimented with a whole suite of things including alternative payment models, pay for performance, and investing in health information technology.
And as much as people love criticizing EHRs, the truth is that when President Obama took office, American health care was being primarily delivered on paper. Today, American health care is being delivered primarily electronically. It's not great; we have some progress to make on the quality of that electronic system. But we've built the roads that we need to get to a much more efficient health care system, and the Obama administration deserves a lot of credit for that.
Where I think there is less clear evidence of success is on the cost and quality side. Did the ACA appreciably make quality better? I would say it's not really clear. Has it bent the cost curve? I think it's very hard to see it in the evidence. If you're going to be an optimist, you say, "These things take a long time, and we've got to give these new programs a couple more years." And I think that's entirely feasible. But I think people who declare that health care is dramatically better quality and lower cost—I just don't see that in the data.
VP, health policy, ML Strategies; former health policy advisor and acting health policy director, Senate Finance Committee Chair Chuck Grassley (R-Iowa)
President Obama rightly deserves significant credit for doing a lot of the heavy lifting on the passage of the Affordable Care Act at the most critical time. The ACA, as passed, significantly reduced the number of uninsured.
The president erred in ever saying, "If you like what you have you can keep it." It was not true; many people saw their coverage change and in ways that they didn't like. That line still haunts the perception of the law to this day.
Professor of political economy, economics, and public affairs, Woodrow Wilson School, Princeton University; member, National Academy of Medicine
There is no short answer to the question of how Obama changed health care. In general, Democrats have long dreamt of a world in which health care is available to all Americans when they need it, on roughly equal terms, which means without suffering financial distress as a result of medical bills. Obamacare was a sincere attempt to slouch in that direction.
“I have always maintained that Obamacare was not as revolutionary as the press made it out to be.”
Princeton professor Uwe Reinhardt
However, Obamacare was focused mainly on the uninsured and the market for individual and small group policies. To fix that market in the direction the Democrats wanted it to change is like sowing a ragged latch onto an equally ragged overall system. It is unavoidably messy and complex. It raises numerous technical actuarial problems and administrative problems. And that is why Obamacare has been so messy and why it has recently run into actuarial problems, such as the high premium increases. It is important to note that Obamacare has not driven up the cost of actual health care. It has merely increased the premiums for the Obamacare risk pools.
I have always maintained that Obamacare was not as revolutionary as the press made it out to be. It has been an unglued patch on an ugly overall system of health care financing. The bulk of U.S. health care was not really much touched by it, aside from some Medicare demonstration projects.
Resident Fellow, American Enterprise Institute; former senior health economist, United States Joint Economic Committee
In order for the president and Democrats to accomplish their goals, including increasing coverage, they took on other losses and liabilities. By rewarding some Americans with generous subsidies, they had some collateral casualties of folks who were not happy about the policies they lost or the insurance arrangements they had to change.
It was a political miscalculation for them to think they had such a great idea that people would welcome it. It turned out that the ACA created more acrimony and division. They kept saying, "Next year will be better, next year you'll really appreciate it." And that next year never really quite arrived. They literally set a historical record for the longest continuing significant opposition to a major health care entitlement.
The administration also entered new territory in administrative law space. They made up stuff that wasn't in the law and took the statutory text as just a suggestion, such as with the employer mandate. That's not a force for predictable regulation and accountability government, but it certainly opened up ways to improvise on the fly with a difficult statutory text, which may be reversed in the opposite direction in the administration to come.
There was also a lot of acrimony and bitterness in federal state relations. That's not across the board: Some states very much welcomed Medicaid expansion and the marketplaces. But if you want to get historical about it, the Obama administration somewhat fell short of conquering all the southern states; I would say General Sherman had more firepower and willpower when he accomplished it in the 1860s, apparently the White House didn't quite have the heart to follow through on the offensive. And we are where we are on the Medicaid and exchanges fronts as a result of the states that have not yet come on board.
Professor of law, University of Michigan Law School; former attorney with the appellate staff in the Civil Division, U.S. Department of Justice
President Obama appreciated three truths about the health care system.
First, you've got to build on what's there, not rethink the whole system in one fell swoop. Second, a stable insurance market can work only if it includes both the healthy and unhealthy. And third, covering people costs money, which means you have to either raise taxes or cut spending.
Accepting these truths didn't always make President Obama popular. But it allowed him to move the country much closer to universal coverage.
Professor of economics and health policy, Carnegie Mellon University; governing board chair, Health Care Cost Institute
Obviously the passage and implementation of the Affordable Care Act was a landmark moment in health policy and has greatly expanded the number of people with health insurance coverage.
“The passage and implementation of the Affordable Care Act was a landmark moment in health policy and has greatly expanded the number of people with health insurance coverage.”
Carnegie Mellon professor Martin Gaynor
I think they got a lot right with the ACA; like anything else, there are some things that could be done better. The ACA made a huge amount of progress on getting individual health insurance markets to work reasonably effectively, but everyone acknowledges that if the ACA is to continue, there needs to be changes. The markets are far from falling apart, but some modifications are in order. I don't view that as a failure—with any major program you'll need to make modifications as you go along.
On cost control, health care spending growth in the United States has moderated greatly, particularly for the Medicare program. So something good is happening, but how much of that is due to the Affordable Care Act is hard to say.
Some other things that happened under the Obama administration that were beneficial, even if they weren't flashy, have to do with competition. The federal antitrust enforcement agencies have been very active, and not just in going after big headline mergers, but also on smaller things—like state licensing boards, Certificate of Public Advantage, the state-action immunity doctrine, and occupational licensing—that affect the competitive market environment and have profound impacts.
These are things that don't make headlines and don't change the entire health system, but they do start to help make the markets that we rely upon in health care work better.
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