What We Got (and What Might Have Been): A Distinctly American Approach

The 2010 Affordable Care Act (ACA) comprises two laws: the Senate version of the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reform Act (HCERA). Two bills were used to create the health reform law when Democrats lost the majority needed in the Senate to pass a negotiated version of health reform that could avoid the use of the Senate filibuster by Republicans who opposed the bill. The ACA includes ten major titles and hundreds of provisions. Provisions include an expansion of health insurance coverage for individuals and small groups who lack access to affordable as well as substantial reforms of insurance practices in those markets, including prohibitions on denials of coverage based on preexisting conditions, charging women higher premiums than men, and charging elderly consumers more than three times premiums offered to younger consumers. In addition to coverage, the law devotes the most attention to reforming the healthcare delivery system. Almost 70 % of the pages and provisions in the law are related to the healthcare delivery. While quantity does not measure impact, in this case it reflects an intentional effort by Congress to focus on improving the delivery of care. ACA uses a distinct approach to delivery system reform with three notable features: (1) makes improving the quality and safety of care, rather than cost savings, the primary goal of delivery reform, (2) redirects Medicare and Medicaid payments away from pure fee for service and toward value-based care, and (3) seeks to make delivery system reform self-sustaining. What might have the health reform law included compared to what Congress passed? Probably a much scaled-down version that only extended coverage to children. Such a bill may have garnered some Republican support and have been easier to pass. But it would likely have neglected all or most of the delivery system reforms that seek to improve care for all patients in the USA.