Ten years ago, the Affordable Care Act was signed into law. This landmark legislation opened the “front door” to the U.S. health care system for millions of Americans who previously lacked direct and orderly access to that care.
While not without its faults, the ACA fundamentally changed the health care coverage landscape. Thanks to policy changes affecting both public and private markets, more than 20 million people gained access to health coverage. Nearly half of this increase came from expanding Medicaid to more low-income Americans and making enrollment easier to navigate. In the midst of responding to the COVID-19 outbreak, we see how important it is to have this additional safety net in place while people are facing economic challenges exactly when they need access to care the most.
In the private market, the law allowed young adults to stay on their parents’ plans until age 26. In offering new protections for people with pre-existing conditions and establishing age-adjusted community rating, the ACA effectively eliminated medical underwriting from the individual insurance market. It also created essential health benefits — a set of standards that all compliant health plans must meet — including maternity care and mental health care. This, together with a comprehensive risk adjustment model, went far toward eliminating insurance market competition based on favorable risk selection. To help moderate- and low-income people access this more robust coverage, the ACA offered subsidies to reduce monthly premiums and out-of-pocket expenses. The power and structural value of these subsidies has been made abundantly clear as the markets have held relatively stable even in the absence of an enforceable national mandate to maintain coverage.
To be sure, access and affordability challenges still exist for many Americans. Despite these shortcomings, the ACA has provided access to coverage for millions of people who otherwise could not have afforded it.
Kaiser Permanente is proud to have been an early leader in embracing and aggressively implementing the law. Our teams have worked hard to operationalize the law, ensuring choice and access to high-quality health care coverage in these new and expanded ways.
Looking ahead to the next 10 years
This experience gives us hope for what public-private partnerships can accomplish as we work toward expanding coverage and improving affordability nationwide. We have proven that, by working together, we can better foster competition in the marketplace to the benefit of consumers — through lower costs and high-quality coverage options.
While we’ve made significant coverage gains, as an industry we still have much to do to improve affordability and refine our mission to deliver more health, not just more care. This means sharpening our focus on delivery system reform and incentivizing coordinated, quality care.
In this sense, Kaiser Permanente is atypical. Our integrated approach to care — which ensures that a team of doctors, nurses, pharmacists, and other health professionals coordinate care to focus on the needs of each patient — is supported by an economic model that is incentivized for quality, prevention, and resource stewardship, and not to drive increased per patient revenue and volume. Stripping away incentives that encourage more care rather than better care requires health systems and plans to adopt a new population-based framework. As a nation, we’re not quite there yet, but clearly this is where we need to go.
Americans agree that our job is not yet finished, and the majority are supportive of efforts to build on this landmark legislation to ensure all Americans have access to high-quality, comprehensive health care coverage they can afford. We are speaking a different language 10 years out. We are thinking much more about prevention, mental health and wellness, and the need to expand access to health-related social services. We are also beginning to think about systematically building a future workforce that doesn’t just replicate and reinforce old ways of doing things, but prepares us for the health and social needs of Americans today and tomorrow.
The circumstances of the ACA’s enactment cut short the process of transforming how we deliver health care to the same extent it transformed health insurance. That work is even more urgent now. It’s often said that a more effective and affordable health care system in the future will have all practitioners providing care “at the top of their licenses.” This is true, but even more valuable will be a future health system in which practitioners work together, in highly functioning teams, to meet the needs of both their patients and the entire population. A key goal of Kaiser Permanente’s new Bernard J. Tyson School of Medicine is to train the next generation of physicians to be the leaders of these care teams. It is just one aspect of how we are planting the seeds for the kind of health care system we all want to see — and all can benefit from.
We look forward to working with policymakers and other industry leaders to bring about this much-needed change in the next decade and beyond.