U.S. Health Care Reform: Cost Containment and Improvement in Quality

President Obama is the only sitting president of the United States in modern history to publish an article inJAMA. That seems appropriate since he is also the only recent president to sign comprehensive health reform legislation, the Affordable Care Act (ACA). The president adopted a dual mandate for the ACA: it needed not only to expand coverage but also to contain costs (despite the additional utilization associated with the increased coverage) and improve quality.

Numerous pundits on both the right and the left indicated that it was a mistake to tie these goals together, but other experts maintained that the president’s approach was the only feasible one. In any case, it is difficult to argue with the results: fundamentally, the ACA is working. An estimated 20 million more people are insured because of the law, the increase in health care costs has declined sharply, and health care quality is improving following its enactment.

The Special Communication by the president breaks some new ground; for example, by renewing a call for a public option on the exchanges created by the ACA. Mostly, though, the report is a compendium of the numerous positive outcomes related to the law to date and how the worst concerns (from creating massive job loss to substantial access problems) have proven almost entirely untrue. However, robust evidence demonstrating the actual health benefits of the coverage expansions is more tenuous than suggested, and the article does not revisit medical malpractice reform (focused on safe harbors for evidence-based care).

Rather than caviling over these minor points, however, this editorial will focus on what has proven surprising since the ACA was enacted and the path forward.