Ezekiel J. Emanuel - The Trillion Dollar Revolution: How the Affordable Care Act Transformed Politics, Law, and Health Care in America

To my grandchildren

Yonah, Anina, and Lincoln

As part of my effort to improve the American health care systemand societyfor you and your fellow citizens

E. J. E.

To my children

Ollie, Ryan, and Ruthie

Proof that the future is bright, and advocates for the law about doctors and hospitals ever since they could speak

A. R. G.

With President Barack Obamas signature on a Tuesday morning, March 23, 2010, the Patient Protection and Affordable Care Act (ACA) officially became one of the seminal laws impacting American health care.

It was the largest reform of the nations health care system since Congress and President Lyndon Johnson created Medicaid and Medicare nearly half a century before. One could argue it was even larger, as the ACA made structural reforms to both of those programs as well as to the private health insurance market and the nations health care delivery system. Alongside its scale and import, the ACA has also undoubtedly been one of the most controversial laws in modern American history.

As we approach the 10-year anniversary of its passage, it is fitting to look back at the past decade and capture the history of the law, its successes, and its challenges. As we embark on that retrospective, we should do so with a dose of humility. Assessing the full impact of the ACA ten years after its passage is important but probably incomplete.

The lessons we can learn from this laws passage and its implementation can illuminate much about American politics and policy, our health care system, and the ways that decisions made by policymakers affect the lives of the American people.

H OW TO BEGIN an analysis of such a comprehensive and complex law? There are innumerable ways to measure and analyze our nations health care system. But I have always found it most helpful to focus on the 3 questions that matter most to American patients and their families. First, is health care accessible? Second, is it affordable? And third, is it quality care?

Those 3 aspectsaccessibility, affordability, and qualityand their impact on the health of the American people are the through-line of the history of the ACA and this book. And these aspects will guide policymakers as they consider future reforms to American health care.

From where I sit and the experiences I had as secretary of Health and Human Services, a few things are clear.

First, the ACA helped more Americans access health care. An estimated 20 million Americans gained coverage due to the ACAs Medicaid expansion, subsidies to afford private health insurance through the Health Insurance Marketplace, and various reforms to the health insurance market like allowing young adults to stay on their parents health plan until they turn 26. These reforms led to the lowest uninsured rate in American history.

Many of those previously uninsured were the people who needed coverage the most. Cancer survivors, people with chronic conditions, and others who, in the past, were denied coverage because of a preexisting condition were finally protected by the ACAs ban on that practice.

In the years since, we have also uncovered abundant evidence that access to coverage translates into greater protection from financial risk, greater access to care, and, subsequently, better health. Housing stability also improved, as declines in evictions have been associated with the ACAs expansion of Medicaid.

Second, the ACA led to significant progress on affordability. As already noted, the ACA helped more people pay for health care services. Among people gaining coverage, it has led to lower medical debt and greater access to credit. As a result, feelings of financial strain caused

Nonetheless, issues like rising deductibles and the struggles of middle-class families to keep up with health care costs are still quite problematic and a key focus for policymakers today and in the future.

Finally, the ACA massively improved the quality of coverage for people who are currently covered through the individual market, as plans are required to cover essential health benefits; through their employer, as plans are no longer allowed to create lifetime or annual limits on coverage; or through Medicare, as the ACA closed the donut hole in Medicare Part D and now covers preventive services. It also improved the quality of care by reducing re-admissions and hospital-acquired conditions. Yet the United States still has work to do, as we fall behind other major developed nations in many measures and must do more to address behavioral health crises and infant and maternal mortality.

Among these 3 measuresthe accessibility, affordability, and quality of American health carethe Affordable Care Act has directly led to significant progress.

A LTHOUGH NONE OF these achievements means our work on these issues is done, each should be seen in the broader context of an effortnearly unprecedented in modern American historyto undermine and attack the law.

From the early resistance to a traditional technical-fixes bill to the litigation filed the first day the statute was enacted, resistance to the ACA only grew. Modern American history has other examples of resistance to expansions in coverage. In 1961 the American Medical Association hired a well-known actor to record an LP warning that, if the newly proposed Medicare program passed, We are going to spend our sunset years telling our children and our childrens children what it once was like in America when men were free.

Despite all of this, the law at 10 years has proven more resilient than expected. Many times throughout the past decade conventional wisdom considered the ACA finished. Through midterm elections, Supreme Court decisions, a presidential reelection, and an election in 2016 that saw the legislative and executive branches united around repeal, the ACA has nevertheless survived. In fact, it has only grown more popular. The 2018 midterms, where health care was listed as voters top priority, was in many ways a rejection of repeal.