By RICARDO ALONSO-ZALDIVAR
(AP) — Although his signature law is in jeopardy, President Barack
Obama’s work reshaping health care in America is certain to endure in
the broad public support for many of its underlying principles, along
with conflicts over how to secure them.
The belief that people
with medical problems should be able to get health insurance is no
longer challenged. The issue seems to be how to guarantee that. The idea
that government should help those who can’t afford their premiums has
gained acceptance. The question is how much, and for what kind of
“The American people have now set new standards for
access to health care based on the Affordable Care Act,” former Surgeon
General David Satcher says. “I don’t believe it will ever be acceptable
again to have 50 million people without access to health care.”
Obama’s influence will continue in other ways, less visible and hardly divisive:
—Medicare is shifting to paying for value, not just volume.
—The importance of prevention and front-line primary care is more widely recognized.
—Doctors and hospitals have computerized their records systems, even if connectivity remains elusive.
government has opened up massive files of health care billing data,
enabling independent analysts to look for patterns of questionable
But conflict is part of Obama’s legacy, too. He leaves the country deeply divided about the government’s role in health care.
with no Republican votes, the 2010 health care law broke the pattern of
major safety net programs like Social Security, Medicare and Medicaid,
which had bipartisan backing. Social Security has stood for more than 80
years; Medicare and Medicaid for more than 50.
“If Medicare had
been repealed, stories about Lyndon Johnson would have been different,”
said Robert Blendon, professor of health policy at the Harvard T.H. Chan
School of Public Health. “A legacy is whether you did something that
was sustained.” Johnson was the Democratic president who won approval of
Medicare and Medicaid in 1965.
Already, the Republican-led
Congress, taking its lead from President-elect Donald Trump, has started
the process of repealing and replacing the health law.
that partisan are difficult to sustain as lasting, permanent features
of the health care system,” said Mark McClellan, Medicare administrator
under Republican President George W. Bush.
Obama also failed to
deliver on early promises to cut premiums. From 2009-2016, the amount
employees pay in premiums for workplace coverage rose by hundreds of
dollars, according to the nonpartisan Kaiser Family Foundation. And the
average deductible — the annual amount patients pay before insurance
kicks in — went from $533 to $1,221, an increase of nearly 130 percent.
The achievements and difficulties of the Obama years are reflected in people such as Karen Rezny.
“I really do credit Obamacare with saving my life,” said Rezny, a massage therapist from Austin, Texas.
health care law, or ACA, enabled her to get better treatment for
advanced breast cancer. She was uninsured when diagnosed. Before the
law, insurers would have rejected her because of her medical condition.
Even with a subsidized premium, Rezny said she still struggles with
“What I would hope is that we would look back and say
(Obama) got the ball rolling, and then we continue,” said Rezny. “He
took health care off the House and Senate floor — out of theoretical
talk by people who are guaranteed lifetime health care — and actually
allowed the people to experience it and have it.”
When the law
passed, 48.6 million people were uninsured, according to the government.
Through the first six months of last year, that dropped to 28.4
million. While employer coverage also grew as the economy strengthened,
experts credit the ACA for most of the progress. The law provides
subsidized private insurance along with a Medicaid expansion for
“It would have never been done without the
focus and insistence of this president that we go big,” said Kathleen
Sebelius, Obama’s first secretary of Health and Human Services.
Obama set his sights high, but execution was a problem. When HealthCare.gov went live in 2013, the computer system quickly froze. It took a high-tech rescue effort to get things working for consumers.
The law’s complexity also tripped people up. It uses the income tax system to subsidize premiums. Some HealthCare.gov
customers saw their tax refunds reduced because they underestimated
their incomes when applying for subsidies. Fines on those who remained
uninsured hit people in their 30s trying to get traction in life.
Officials in many states were alarmed by rising Medicaid spending.
Republicans won control of the House in 2010, Obama was effectively
blocked from legislating fixes. The administration used regulations to
try smooth out the law’s rough edges, while successfully fighting off
two Supreme Court cases that would have gutted it.
In the face of
problems, the White House ceaselessly talked up the benefits of the law.
Among the controversial claims was that the law deserved much credit
for a historic slowdown in national health care spending from 2009-2013.
nonsense,” said Rick Foster, formerly Medicare’s chief actuary, in
charge of long-range estimates. “Far and away the biggest cause of the
slowdown was the Great Recession. That is not to say that the Affordable
Care Act didn’t have some impact, but I think that was small compared
to the effect of the recession and the weak recovery.”
shows that America’s social programs got built in stages. Automatic
cost-of-living increases weren’t part of Social Security originally.
Medicare didn’t get a prescription benefit for nearly 40 years.
Case of Denver hopes that somehow, something like that can happen with
Obama’s overhaul. She works in customer relations for a technology
company and buys coverage through the Colorado insurance marketplace.
of all the work that has gone into this imperfect thing,” said Case,
“and to just tear it down to make a point, rather than say it’s flawed
but we can fix it.
“Just because you need to do the top floor doesn’t mean you level the entire complex.”