The only thing more complicated than health care policy is health care politics.

While most Americans would agree that everyone should have access to affordable, high-quality health care, it takes decades of struggle to make every small step toward that goal.

Eight years ago last week, President Obama took a giant step by signing the Affordable Care Act, establishing health care as a right for all Americans.

The law that emerged from two years of bruising bargaining and compromise was not any health care expert’s idea of the perfect system. But when you consider what it replaced, this anniversary is something to celebrate.

• In 2009, 44 million people (18 percent of the population) were uninsured. Millions could not buy insurance because of disqualifying pre-existing conditions. Some with insurance had their coverage canceled when they needed it most, because their policy contained a hard cap on benefits.

• Costs were spiraling out of control. This not only affected family budgets, but also exploded the cost of government programs like Medicare, Medicaid and the veterans health system while bankrupting businesses that supplied employee benefits.


• Resources were wasted on unnecessary treatment, with easy-to-prevent infections and errors resulting in expensive repeat hospitalizations. The landmark law that came to be know as “Obamacare” by both its supporters and its enemies has made significant progress in all three areas.


The uninsured rate was cut nearly in half;, with 20 million people covered through expanded Medicaid or private insurance purchased on state exchanges, made affordable for people with lower incomes through tax credits.

Insurance companies can no longer deny coverage to someone with a pre-existing condition, and it would be political suicide for an elected official from either party to try to send us back to those bad old days.

Health care costs are still climbing faster than the rate of inflation, so it’s hard to appreciate that the rate of increase has been cut dramatically. Per capita health care spending grew 50.3 percent between 2001 and 2008, an average of 6.2 percent a year. In the next eight years, per capita spending increased 31 percent, averaging 3.8 percent a year.

Most importantly, as a result of the act, more people got consistant access to health care. Instead of waiting for a heart attack, people are treating their heart disease with medication, diet and exercise. A patient with diabetes can get primary care to manage their condition instead of waiting until they need an emergency amputation. These benefits will compound over time as people live longer, healthier lives.


These are hopeful signs, but even the ACA’s biggest supporters would acknowledge that the law is full of holes. Too many people still lack access to care, costs are still too high and climbing too fast while the crazy quilt of public and private payers and providers drives care decisions that make no sense. The politics of health care has made filling those holes impossible.

Republicans have come to power by undermining the parts of the act that work instead of fixing the ones that don’t. Democrats have used what’s left of their political capital defending the ACA, flaws and all, instead of trying to make it better.

As we saw last week, when Sen. Susan Collins could not even get a vote from Republican leadership on the modest ACA stabilization plan she helped draft, the political challenges make the policy issues look simple.


There is a chance that the politics could be changing, however.

Republicans had success attacking real and imagined flaws of the ACA before people started seeing the benefits. But since taking control of the presidency and both houses of Congress, it looks like they could pay a political price for their efforts to dismantle it. Democrats, on the other hand, are being pushed by their more progressive constituents, who want to replace the entire system with a European-style, single-payer system or “Medicare for all.”


While America should have that debate, there are modest improvements to the ACA that could lower costs while improving access and quality.

As President Trump pointed out again in his speech in Manchester, New Hampshire, last week, Americans pay the highest prices in the world for pharmaceutical drugs. Rising drug costs drive inflation in the system, and limiting increases would keep more people covered and save lives.

There should be no ideological dispute over changing compensation formulas to providers so they can afford to deliver preventive care, avoiding catastrophic costs in the future.

And in areas where there is little or no competition among insurers, states should be encouraged to experiment with a public option, perhaps allowing consumers to buy into an existing program like Medicaid, so there would always be at least one plan to compete against a for-profit insurer.

None of these ideas would be easy to achieve, but all of them are worth exploring.

Obamacare has survived. It’s time to start looking at ways to make it better.

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