Resisting the Rush to Judgement On the Affordable Care Act

A full, fair reckoning of the impact of the Affordable Care Act (ACA) will take years. In an earlier blog post, we outlined some of the measures—such as reductions in rates of uninsurance and underinsurance and trends in health care costs and quality—by which the law should be judged and the time frames over which those judgments should be made.

In the mean time, however, the rush to reckoning seems irresistible. These interim conclusions could prove as faulty as the ACA websites, but they should at least be informed by the best information available. As of this writing, this is what we know about the major shortcomings and accomplishments of the ACA.


  1. Poor management of the launch of the federal website, HealthCare.gov. The reasons for this failure are still emerging, but are likely multiple: management failures by the Obama administration, poor performance by its contractors, design flaws in the legislation itself, the decision by so many states not to run their own websites, a toxic political environment, and other factors.
  2. Poor messaging by the President. In retrospect, President Obama should have prepared the public better for the inevitability that some Americans would be left worse off by the law because of higher insurance prices or the need to switch health plans.
  3. Failure to prepare fully in advance for adverse impacts of the implementation of the ACA. There may have been more such preparation than meets the eye but if, for example, the administration had anticipated that private health plans might be cancelled, the policy response could have been waiting on the shelf. Instead, there was a last-minute scramble under the media spotlight.


  1. Provision of health insurance to: 7.8 million young Americans covered under a parent’s health plan who likely would not have been able to do so prior to the law’s passage, including 3 million who were previously uninsured; more than 200,000 Americans covered through state marketplaces as of November 25, 2013; and 26,794 covered through the federal marketplace as of November 2, 2013.
  2. Refunds of $2.1 billion to consumers in 2012 because their insurers’ administrative costs and profits exceeded ACA limits.
  3. Guaranteed, free coverage of essential preventive care for Americans covered by Medicare or private insurance.
  4. Elimination of the so-called “doughnut hole,” or coverage gap for prescription drugs, under Part D of Medicare.
  5. Implementation of significant payment and organizational reforms, including:
    a. The deployment of 250 innovative accountable care organizations (ACOs) now serving an estimated 4 million people. An ACO is a partnership between an insurer and a group of providers formed to share in savings generated by meeting quality and cost targets.
    b. An apparent reduction in preventable readmissions to hospitals among Medicare patients as a result of new incentives for hospitals.
    c. Increased attention by hospitals to preventing health care–acquired infections.
    d. A vast, nationwide hospital safety improvement program.
  6. Thousands of experiments with new ways to deliver care to the nation’s most vulnerable and high-cost consumers of health care launched under the new Center for Medicare and Medicaid Innovation.
  7. A possible role in slowing the health care cost growth rate to its lowest level in 50 years, a trend that, if it persists, could greatly reduce the federal deficit and free up funds for other vital public purposes.

The accompanying exhibits provide a more complete listing of these and other established or possible effects of the ACA. The breadth of the ACA’s impact so far clearly shows the discussion of the successes and failures of the ACA needs to extend well beyond the narrow focus on website functioning, enrollment in the federal website, and the cancellation of some health plans.

Exhibit 1

Exhibit 2

David Blumenthal, M.D., M.P.P., is president of The Commonwealth Fund, where this post originally appeared.

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47 replies »

  1. Its like you read my thoughts! You seem to know a lot about
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  2. Note to Archon41:

    For almost 60 years, Young voters have been subsidizing the medical expenses of older persons who very often have higher net worths. (through Medicare taxes)

    Meanwhile older persons with no children at home subsidize education for young families (through state and local taxes).

    Both Medicare and public schools are not means-tested. They go to people rich and pool as long as they are citizens (and sometimes not even citizens).

    As such these programs do contain some spillover in the sense of poorer taxpayers kicking in something for richer beneficiaries.

    But in my opinion, the value of social solidarity makes me OK with this.

  3. Come 1-1-14, I will be cruising in the “Cadillac” of Medicare Advantage. The awareness that I will not receive much the same “quality of care” as Harry Reid or Donald Trump causes me little chagrin. The Greeks had a word for the mantra of “redistribution”: “pthonos”–the spirit of envy, jealousy, and spite.

  4. “It will also occur to many of them to wonder why they should be subsidizing the expenses of those with greater net worth than their own.”

    That has been happening all along with tax free subsidized employer health care. Maybe the tax on cadillac plans will be a start.

    So #41 are you in favor of paying the tax on the benefit?

  5. 1. “Passed before knowing what’s in it”.

    2. Horrible website rollout, knowing that naysayers would be rubbing their hands in glee.

    3. Numerous unintended or thought out consequences that have yet to reveal themselves due to #1.

    That’s all I need to know.

  6. Should public support for the ACA continue to deteriorate, I think it more likely than not that the individual and employer mandates will never be put into effect. This leaves the fate of the exchanges problematic. Obviously, many voters are balking at shouldering the medical expenses of others, and railing at them for being selfish and mean-spirited will be counterproductive. It will also occur to many of them to wonder why they should be subsidizing the expenses of those with greater net worth than their own. Hopefully, serious attempts to mitigate the cost of health care will emerge from this moil and toil. Universal single-payer collectivized health care will not be a contender here. Its proponents seem blind to the fact that their visions unite against them the providers, everyone who wishes to retain his present quality of care, the insurers, and even the trial lawyers.

  7. Peter1 –

    The spread between what specialists and primary care doctors earn within the U.S. is a separate issue and, I think, easier to explain. Simply put, it takes more years of training and working long hours for relatively low pay to become a specialist yet specialists’ life expectancies are no longer so they have fewer working years ahead of them once they become fully credentialed. We can argue about what the appropriate spread should be but there should be a spread just from a return on investment standpoint.

    As for people who choose to become a doctor because that’s what their father did, I don’t buy it. Some do but most don’t. People have different natural abilities and personalities even among siblings. Of all the people I worked with at four different firms during a 40 year career in the money management business, virtually none of my colleagues had fathers who worked in the same field.

    After I wrote my last post, I found a term used by economists called the Law of One Price or LOOP which says that pay in other fields requiring the same or less education and training influences decisions to pursue one field over another when the basic abilities to succeed are there. As this article noted, if you want to see doctors earn less money in the U.S., hope for lower pay on Wall Street! Personally, I think U.S. primary care doctors are largely underpaid but I also think NP’s should be allowed to practice at the top of their license without supervision by a physician.

  8. ” I think one of the reasons U.S. doctors are paid more than their counterparts in other countries is because the opportunity cost of what they could have earned in other industries like finance or real estate is considerably higher in the U.S.”

    Barry, I’ve known docs that I wish had chosen another profession. Trying to apply that assumption to general practitioners doesn’t explain why they earn much less than specialists. People choose their profession for a number of reasons, mostly from what their daddy did. Medical compensation I think is mostly a rigged system.

  9. Bob –

    As more and more doctors sell out to hospitals and go to work for them for a salary plus bonus, their malpractice premiums are paid by the hospital. However, even if their personal assets are not at risk for any malpractice payout, being sued is stressful. Doctors see it as a potential hit to their reputation just to be sued even if they ultimately win the case. Sitting for a deposition is stressful in itself and preparing for it is time consuming. The case can drag on for years before it’s resolved. It all adds up to a determination to avoid being sued at all costs which results in lots of defensive medicine.

    I think one of the reasons U.S. doctors are paid more than their counterparts in other countries is because the opportunity cost of what they could have earned in other industries like finance or real estate is considerably higher in the U.S.

    One factor that I’ve never seen a good discussion of or study about is how the pervasive attitude among patients in the U.S. that more care is better care and more expensive care is better care compares with attitudes of patients in Canada and Western Europe. As patient satisfaction becomes more of a factor in evaluating doctors, it adds to the pressure to give patients what they want with regard to testing even if the doctor doesn’t think it’s necessary. Think imaging here.

    I have seen it suggested that people in other countries are more accepting of death when the time comes whereas lots of people in the U.S. will want an expensive full court press even if the doctors think the prognosis is between dire and hopeless.

    Finally, I’ve suggested several times before that it would be useful to see a comparison of the number of hospital employees per licensed bed in U.S. academic medical centers and community hospitals vs. their counterparts in Canada, Western Europe, Japan and Australia. It would likely show that the cost structure of U.S. hospitals is significantly higher even excluding differences in billing costs. However, I’ve never seen or even heard of such a study. Maybe CMS or an entity like the Robert Wood Johnson Foundation should fund one.

  10. Bob, Canadian docs never think they’re well paid, they use U.S. compensation as their benchmark. In Ontario the government even pays part of their malpractice insurance. There was a time that docs could own labs, that led naturally to over testing to their own facility.

    It never ends.

  11. It is my understanding that Canadian doctors are overall well-paid, despite the low fees in their Medicare, and their complete inability to do balance billing of patients.

    I am not sure how this occurs, but it might be worth studying.

    One thought I have had for some time is this:

    if America put medical education on the federal budget, and established a kind of nationalized malpractice insurance, then doctors might not need high fees to stay solvent.

    The two steps I just described might total $30 billion in federal spending. We spend that much on Medicare about every 18 days.

  12. Poll: Obama Hits New Low on Healthcare (The Hill, Healthwatch, 12-10-13)

    “According to the survey, 60 percent disapprove of how the president has handled the issue, against only 36 who approve.” (Poll conducted by Quinnipiac)

    Wonder when the party faithful are going to be rolling out that “PR messaging” push?

  13. Peter1 –

    Since insurers must now offer a mandated set of essential benefits and they can no longer exclude people based on pre-existing conditions, aside from age and smoking status, the only way they can impact premiums is through the breadth or narrowness of the network. Also, individuals buying their own insurance either with or without subsidies are likely to be extremely price sensitive vs. people who get their health insurance through an employer. Therefore, the excluded hospitals and doctors are, for the most part, being excluded because they want higher reimbursements than other providers in the narrow network are willing to accept.

    As many have noted before, the care provided by the more expensive providers is not likely to be any better, at least for the vast majority of services, tests and procedures than what’s provided by the less expensive doctors and hospitals.

  14. I report, you decide. But it really sounds to me like neither side is carried away by your sense of “spiritual uplift.”

  15. I need to know if this is because those excluded docs and hospitals just want too much money. Is this insurance or providers saying no to Obamacare.

  16. “Blue Shield of California has said it will include just 50% of the physicians and 75% of the hospitals in 2014 than it did in this year’s individual plans.” (Insurers Are Renegotiating Contracts,Narrowing Networks under ACA, California Healthline 12-10-13.)

  17. There’s a big difference between “30% would retire today if they could” and “California is going to lose 1/3 of the population resource” specifically because of Obamacare.

    Most are going to do what I’m going to do, i.e., not participate in the exchange plans and just continue with my already way-too-big groups of established patients.

    Yes, physicians are a miserably unhappy group, but the actual causes of that unhappiness predate Obamacare by several decades.

  18. All I can find is California. When Canadian medicare was proposed the doctor community were the loudest opponents. After it was passed and expanded to all provinces surprisingly most doctors participated. It’s been a steady fight ever since with unsuccessful doctor strikes that the public did not support. It’s always about pay.

    Given that medicine is isolated from most economic downturns maybe the docs would like to go to another industry and see how that works out.

  19. As long as responsible and credible commenters note it is both sides being disingenuous and dishonest with using stacked stats and biased surveys and polls, then I have no qualm with the comments.

    But, the partisan hackery that pervades here, from both sides again, is just in poor taste!

  20. you are kidding about asking why some would retire, right?! I have yet to do a llnk here, so if it doesn’t work, I will then add the comment in the article to note my position:


    from it: “Obamacare is further thinning the doctor corps. A Physicians Foundation survey of 13,000 doctors found that 60 percent of doctors would retire today if they could, up from 45 percent before the law passed.”

    So, it isn’t Joel Hassman saying this, it is our colleagues!

  21. “More media hype” ???

    Not sure what they’re boycotting. Patients with insurance? Patients on Medicaid, Medicare? If they have existing contracts with insurance how will they know which patients are covered on the exchange or not?

    As for “hype” here’s one example:
    “Real doctors decide the course of treatment for patients—bad doctors don’t care that death panels and bureaucrats who never stepped inside a medical school…”


  22. archon41- these are greedy doctors who are HIGHLY resistant to necessary change- I say to them good riddance. Start a business!

  23. Joel- agree that both sides are guilty of media hype- Hey Joel-media is a business just like the former profession of medicine.

    The most crass examples of media hype in medicine is when they start hauling our kids with terminal cancer and using them as political pawns

    Very despicable behavior

  24. Jeff – You clearly missed Dr Blumenthal’s point. The fact that the decline in cost growth began in 2005-6 not only proves that the ACA can bend the cost-curve going forward, it proves it can actually alter the space-time continuum to bend the cost-curve going backwards! In other news, the ACA can also wash your dishes and walk your dog.

    The question I have for Dr Blumenthal is whether his going forward assumption is correct in light of the recent report of the Office of the Actuaries for CMS? In it they reduced the overall projected growth of healthcare costs through 2019 due to what they specifically describe as “non-ACA related” factors but raised their projection of ACA related costs by 4.7% during the same time period.

  25. More media hype: “An estimated 7 out of every 10 physicians in deep-blue California are rebelling’against the state’s Obamacare health insurance exchange and won’t participate, the head of the state’s largest medical association said.” (Doctors boycotting California’s Obamacare exchange, Richard Pollock, Washington Examiner, 12-6-13.)

  26. Why, because Fox does not genuflect to Democrat partisan agendas, like, this legislation?

    Care to share some examples of Media hype that is irresponsible, by, let’s see, Fox’s polar opposite MSNBC!?

    These threads really do bring out the best and brightest of the apologists and defenders, do some agree with me?

  27. Gee, some refer to Nazi Germany and Communist Russia as “periods”, so would you call those specs on the windshield too?!

  28. Umm, reality check here, people will not pay out of pocket as the trends show over 85% going into Medicaid, so, if a doc does not participate in the insurance plan, the patient is not going to be seen by said doc.

    Oh, and you know what most of these docs who won’t participate are going to be doing as of 2015? Over 30% will retire or leave the state, count on it!

    What are some of you here, ostriches? Doesn’t that sand get annoying, in the mouth and nose, forget what happens to the eyes!!!

  29. I’m okay with rushing to judgement on the immoral behavior of the drafters and proponents of this law who blatantly lied to the American people in order to ensure its passage: You can keep your policy if you like it; You can keep your doctors if you like them; Your premiums will go down.

    I’m okay with rushing to judgement about the lack of empathy displayed by the politicians and technocrats responsible for this mess as millions, including family members of mine, lose the coverage they were satisfied with and which you promised they could keep.

  30. What is perhaps most interesting about this post from Dr. Blumenthal, the former ONC for HIT, is that there is no mention of what effect meaningful use ($12+ billion paid out to date) has had on health care costs.

    Sometimes, what is not said is most informative.

  31. The problem ACA has is that it will get logarithmically worse as time progresses. Any anger that exists now over the website or the lies told to sell it is a rounding error in comparison to what’s coming.

    It’s not easy or wise to try to change 1/6th of the economy in one fell swoop.

    Withholding one’s judgement or being extremely optimistic is not going to prevent or lessen the negative effects that this poorly architected bill is going to have not only on American healthcare, but our entire economy.

  32. “The docs say they won’t be accepting the new plans the insurers are selling on the exchange.”


    You may be right, I doubt the legislation compels any doc from accepting any plan. Possible outcome could be extra billing over paid insurance, which would defeat the “affordability” part.

    In Ontario Canada extra billing became a big issue. It was a way for docs to circumvent single-pay negotiated rates. Province banned the practice, no mass leavings, but in many areas, as in U.S., PCPs are hard to come by.

  33. ” Even if that stat is off by 50%, can Californians afford to lose 1/3 of the physician population as a resource?”

    Wrong. The docs say they won’t be accepting the new plans the insurers are selling on the exchange. They’re not retiring or leaving the state.

  34. “Period.” Period, period, period. Let us not be distracted by the smallest character on the keyboard. It is but a fly spec on the windshield of history.

  35. Defenders and apologists, where would the snake oil salesmen and women be without them, eh?

    I heard last night on O’Reilly’s The Factor that almost 70% of doctors in California will not participate in Obamacare. Even if that stat is off by 50%, can Californians afford to lose 1/3 of the physician population as a resource? Oh, at this blog and other antiphysician sites here on the net, they are just foaming at the mouth to spew their drivel how all the allied health care adjuncts will fill the void of less MD care and there will be no loss of services nor outcomes for patients.

    I don’t type that stupid LOL crap, I just write it as it is:

    Except the people losing their doctors, who know better than to not listen to the David B’s above but know what the law is honestly and being well read NOW to do, these patients are not laughing. No, they are getting angry. But, who do you think will get the brunt of the public outrage?

    Yep, those same doctors who are doing the right thing, having to put up with a sizeable majority who still think physicians owe everyone else and basically should be taking that vow of poverty now.

    Sorry, don’t wear a black collar with a white cardboard attachment in the front! Better realize that now, the defenders and apologists will be telling you falsely otherwise!!!

  36. It’s disappointing to hear David, someone I’ve known for a long time and really respect, repeat the tired and completely indefensible claim that ACA is responsible for the ten year long trend of declining health cost growth.
    I guess since there is no single cause, but perhaps a half dozen, one could lob a political cause in there and not be definitively refuted.

    What ACA has done in the provider community is mainly create a tremendous amount of fear and confusion.

    See: http://healthaffairs.org/blog/2012/05/07/barking-up-the-wrong-tree-affordability-not-cost-growth-is-the-policy-challenge/ for my take on this.

  37. “President Obama should have prepared the public better for the inevitability that some Americans would be left worse off by the law”

    And Bernie Madoff should have prepared his “investors/marks” better for the inevitability that some of them would be worse off by trusting his faulty plan. But let’s not rush to judgment on Ponzi schemes. Consider the fact that telling people the truth about the scheme may have reduced the support for it in the first place. So let’s back off on Bernie because he only lied about his plan because otherwise not enough Americans would have bought into it.

  38. Key Shortcomings — add:

    Shaky theoretical framework:

    too reliant on magical thinking (technology will accomplish what bureaucracy has been unable to in the past, untrue) and ideologically-driven economic assumptions (free market will magically solve problems, it won’t)