2010–2020

By 2014, most of the law’s provisions had taken effect. 32 million uninsured people would gain health insurance coverage by 2020. The law’s impact varied from state to state, particularly with respect to health insurance exchanges (HIXes). In some states, HIXes effectively reduced both the number of uninsured and the cost of health insurance for the already insured. In states where the exchanges offered little choice, the large numbers of uninsured were converted to large numbers of underinsured.

Newly covered prevention services contributed to improved health for many. Demonstration projects and policy changes included in the ACA reduced the age-adjusted per-capita cost of care delivered by Accountable Care Organizations (ACOs). Still, the growing number of people seeking insured care and the aging cohort of Baby Boomers combined to drive up total medical costs. Payers instituted new policies to drive down payments, but provider shortages and physician opposition reduced their ability to do so. By 2018, the Secretary of Health and Human Services was forced to initiate a global annual budget cap for Medicare and stringent usage caps for Medicaid, calling on the private sector to follow suit. Employers and governors followed the federal lead, offering only capitated plans. Over the next three years, most care nationwide came under capitation payment in integrated systems with some additional incentive payments for service providers who meet the relevant quality standards. These systems helped constrain the growing costs for medical care. The overall quality of experience for many patients improved as well.

Population health improvement came much more slowly. Despite the prevention coverage in the ACA and the initiatives of the National Prevention Strategy, obesity and diabetes rates continued to climb. Cancer incidence rates declined, but the aging population made breast and prostate cancers more prevalent. By 2020 health care accounted for 20 percent of GDP and population health measures showed the U.S. still lagging far behind other OECD countries. As a result, health – not health care – became a major election issue in 2020 as candidates debated how reform of health care had failed to adequately improve the nation’s health and to slow the growth of health costs.

With the campaign slogan, “It’s our health, stupid!”, catching on with the American public, the 2020 election set the stage for the second phase of health care reform, including a greater emphasis on non-medical factors affecting population health. Over the 2010’s, comparative effectiveness studies using years’ worth of data from electronic health records had shown that enhanced health system performance and attention to the social determinants of health offered new and better ways.