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Reflecting on Health Reform: A Balanced View of the Affordable Care Act


A full, fair reckoning of the impact of the Affordable Care Act (ACA) will take years. In an earlier blog post, we outlined some of the measures—such as reductions in rates of uninsurance and underinsurance and trends in health care costs and quality—by which the law should be judged and the time frames over which those judgments should be made.

In the mean time, however, the rush to reckoning seems irresistible. These interim conclusions could prove as faulty as the ACA websites, but they should at least be informed by the best information available. As of this writing, this is what we know about the major shortcomings and accomplishments of the ACA.


  1. Poor management of the launch of the federal website, The reasons for this failure are still emerging, but are likely multiple: management failures by the Obama administration, poor performance by its contractors, design flaws in the legislation itself, the decision by so many states not to run their own websites, a toxic political environment, and other factors.
  2. Poor messaging by the President. In retrospect, President Obama should have prepared the public better for the inevitability that some Americans would be left worse off by the law because of higher insurance prices or the need to switch health plans. 
  3. Failure to prepare fully in advance for adverse impacts of the implementation of the ACA. There may have been more such preparation than meets the eye but if, for example, the administration had anticipated that private health plans might be cancelled, the policy response could have been waiting on the shelf. Instead, there was a last-minute scramble under the media spotlight.


  1. Provision of health insurance to: 7.8 million young Americans covered under a parent’s health plan who likely would not have been able to do so prior to the law’s passage, including 3 million who were previously uninsured; more than 200,000 Americans covered through state marketplaces as of November 25, 2013; and 26,794 covered through the federal marketplace as of November 2, 2013. 
  2. Refunds of $2.1 billion to consumers in 2012 because their insurers’ administrative costs and profits exceeded ACA limits. 
  3. Guaranteed, free coverage of essential preventive care for Americans covered by Medicare or private insurance. 
  4. Elimination of the so-called “doughnut hole,” or coverage gap for prescription drugs, under Part D of Medicare. 
  5. Implementation of significant payment and organizational reforms, including:
    a. The deployment of 250 innovative accountable care organizations (ACOs) now serving an estimated 4 million people. An ACO is a partnership between an insurer and a group of providers formed to share in savings generated by meeting quality and cost targets.
    b. An apparent reduction in preventable readmissions to hospitals among Medicare patients as a result of new incentives for hospitals.
    c. Increased attention by hospitals to preventing health care–acquired infections.
    d. A vast, nationwide hospital safety improvement program.
  6. Thousands of experiments with new ways to deliver care to the nation’s most vulnerable and high-cost consumers of health care launched under the new Center for Medicare and Medicaid Innovation. 
  7.  A possible role in slowing the health care cost growth rate to its lowest level in 50 years, a trend that, if it persists, could greatly reduce the federal deficit and free up funds for other vital public purposes. 

The accompanying exhibits provide a more complete listing of these and other established or possible effects of the ACA. The breadth of the ACA’s impact so far clearly shows the discussion of the successes and failures of the ACA needs to extend well beyond the narrow focus on website functioning, enrollment in the federal website, and the cancellation of some health plans.

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Publication Details



D. Blumenthal, Reflecting on Health Reform: A Balanced View of the Affordable Care Act, The Commonwealth Fund Blog, December 2013.