Supporters of the Affordable Care Act tend to get gloomy about the threats haunting every step along its path to implementation, seeing the negatives more clearly than they perceive the positives. As an antidote, I offer 10 reasons to be optimistic about health reform’s progress and prospects.
1. A lot of Americans are being helped by reform every day. Who? Four and a half million early retirees, 3.2 million seniors protected from the doughnut hole and 2 million more kids in Medicaid and CHIP; plus the uncounted millions who now have coverage of clinical preventive services, the many families that can keep adult children up to age 26 on their health plans, the consumers now protected by the prohibition of rescissions and many, many more. If these benefits are not recognized adequately by those receiving them, just wait until there is a genuine threat to eliminate them.
2. Because of the health law, a wave of innovation is now energizing the U.S. health system — driving the most vibrant reform atmosphere ever. Affordable care organizations; medical homes; disease prevention and wellness initiatives; anti-fraud and abuse efforts, insurance exchanges — these are all part of the series of dynamic change processes triggered by the overhaul. Even in terms of health care workforce reform, despite a congressional stalemate that is stalling the launch of the new Workforce Commission, the field is exploding with activity, according to George Thibault, president of the Josiah Macy Foundation, which focuses on workforce innovation. Contrast this dynamism with the funk following the 1994 collapse of the Clinton Health Plan.
3. The Obama administration has managed successfully the development of a lengthy list of complex and politically charged regulations to implement the law. Each process faced a chorus of critics predicting negative outcomes. Instead, skilled professionals at the Departments of Health and Human Services, Treasury and Labor, as well as the White House, mastered each controversy, worked through the minefields and established the parameters of a new health care marketplace that puts consumers and patients first.
4. The administration has demonstrated how flexibility can show strength, not weakness. Waiver approvals involving medical loss ratios and annual limits have been dissed by critics. Yet one can easily imagine their opposite complaints of rigidity had the administration denied any waivers. The key date is 2014, not 2011, and the Obama team has kept its eyes on that goal. President Barack Obama’s embrace of state experimentation is another welcome sign that strengthens rather than undermines the measure’s future.
5. As the dust settles, the constitutional challenges seem a lot less scary. The scorecard of major decisions is 3-2 in favor of the individual mandate. Charles Fried, Ronald Reagan’s solicitor general, told a Senate panel: “The health care law’s enemies have no ally in the Constitution.” Increasingly it is clear that a decision based on the law will uphold the ACA’s most controversial provision, and a ruling based on politics will go the other way. And if the mandate goes down, there are other approaches at hand.
6. All key stakeholders are all sticking with the law. No observable erosion in support has occurred among hospitals, physicians, pharmaceutical/biotech/medical device companies, labor groups or consumers. In January, House Republicans predicted substantial desertions by House Democrats, and wound up with only three Democratic votes for their repeal effort. The only visible chink is on the other side of the debate — the business community’s evident non-interest in hyping repeal. In state after state, the hard work of implementation is moving forward.
7. An improving economy will help. In 1988, Massachusetts passed a major health reform law, which preceded a major economic downturn by months. The ensuing collapse destroyed any chance for implementation. Conversely, had the Clinton health reform plan passed in 1994 while the national economy was still crawling out of a downturn, implementation in the mid-to late-1990s would have been much easier than that early Massachusetts experience because the nation was experiencing an economic boom. The best time to pass major health reform legislation is near the bottom of an economic downturn, with implementation happening when the economy is back on track. And that is how it will play out this time around for the health law.
8. The federal deficit is a growing advantage. When the overhaul was signed in 2010, the Congressional Budget Office estimated$143 billion in 10-year deficit reduction — from 2010 to 2019 — because of the law. In February, the CBO updated its 10-year deficit reduction estimate — spanning 2012 to 2021 — to $210 billion. That number will grow year by year as the measure’s savings and revenues take full effect, making repeal harder and harder.
9. Public opinion is sharply against total repeal, with only 21 percent support according to the March Kaiser Family Foundation tracking poll. (Kaiser Health News is a program of the Foundation.) Overall numbers in public support are still sharply divided — 46 percent unfavorable to 42 percent favorable. Yet on all key elements of reform, except for the mandate, the public supports the law and opposes repeal.
10. The single most devastating blow for implementation would be election of a president who supports the health law’s repeal. Though it is a long way to November 2012, the odds-on favorite now (see Intrade at 64.0 percent — 3/21/11) is the one candidate who supports full and effective implementation of the reform measure.
Can we get through the most challenging implementation of a federal law since the civil rights laws of the 1960s? Yes we can.
John E McDonough is a professor at the Harvard School of Public Health and a former staff member at the U.S. Senate Committee on Health, Education, Labor and Pensions.
