In defense of the Affordable Care Act (aka the “ACA” aka “Obamacare”):

I know that there are a lot of strong feelings about this law for many different reasons. But, health policy is one of the few things I actually know something about so I’d like to take a moment to talk about some of the things this bill really gets right.I know people feel frustrated and feel that it doesn’t go far enough, but what it does is actually monumental for our health system. I’ll list some things here, with some examples for things that aren’t necessarily straightforward, but holler if you want to talk more about any of this anytime! I’m NOT saying it’s perfect (there is no such legislation). I AM saying it does not get enough credit where credit is due. So here are some things this bill accomplished:

- Required coverage for people with preexisting conditions. Ex: I have Crohn’s Disease. If I ever choose to work in, say, a coffee shop that doesn’t provide health insurance, I previously could have legally been denied health insurance from all companies because they would know I have a chronic illness. One of the Crohn’s medications I took for awhile cost $10,000 per shot for the uninsured, and I had to get one every two weeks. I obviously would not have done it if i weren’t insured, but this medication put me into remission. This bill promises me insurance coverage, no matter the type of job I have. (This is just my personal example, but prior to the ACA companies could define what counted as a pre-existing condition, and some denied coverage for victims of domestic violence on these grounds.)

- Eliminated out of pocket costs for many preventive services (immunizations, contraception, etc.) I think it’s easy enough to understand why this is good thing for us as individuals and as a society.

- Eliminated gender rating. Translation: requires insurers to stop charging women higher premiums. Because, guess what, THIS WASN’T ILLEGAL BEFORE (in the individual insurance market — it was illegal in employer-sponsored insurance markets.) Gender rating was justified on the basis that women use more healthcare (b/c of childbirth and “maternal” costs) (b/c LOL only women are responsible for creating children) (also LOL b/c in reality men end up costing more because of higher rates of illness as they age) and resulted in women paying up to 1.5 times what men paid for insurance premiums.

- Individual mandate: the requirement that lots of people hate that penalizes anyone who choses not to buy insurance. Now, I know this is super expensive and still not always accessible BUT having insurance matters. A lot. Ex: Studies have found that insurance status (whether you do or not have insurance coverage) is a greater predictor of survival from colon cancer than the STAGE OF CANCER.

- Concurrent care for children. Kids and parents of sick kids got to stop having to choose between continuing to treat an illness and stopping all treatment for hospice care. So if a child had terminal brain cancer, and chemo was not likely to cure it, but maybe would, or would at least slow growth and help stave off some horrible symptoms, parents had to choose to give that up in order to receive hospice, which would help them in all sorts of other ways including at-home care that helps the child stay at home longer and better symptom management. Now, a parent can continue to fight the cancer, whether in hopes of cure or as palliative treatment, AND get the help of hospice. (This is still not the case across the board for adults, though the ACA did fund an innovation center that has opened this option up in pilot projects for a number of hospices across the country.) I work with a lot of pediatric palliative care providers and they consider this part of the law an absolute game changer for their patients and families.

- Medicaid expansion for governors that were intelligent and humble enough to accept it. This expanded coverage to all people with family incomes at or below 133 percent of the federal poverty line. Which basically translates to getting coverage to a lot more people who can’t really afford it but don’t quite qualify for Medicaid. This affects a lot of people, including my mother, who lives in a state that did not accept the expansion.

- Expanded home visiting programs by creating the Maternal, Infant, and Early Childhood Home Visiting Program, allocating $1.5 billion to states, territories, and tribes to expand home visiting programs and evaluate these programs to ensure they make the intended impact. Home visiting programs have been shown to result in better cognitive development, lower mortality rates, reduced child abuse, and result in fewer days on food stamps.

- Funding more primary care providers expanding the National Health Service Corps and training programs for primary care providers — as of Sept 2015, they had double the number of Corps clinicians providing primary care than 2008. Primary care is important. Think prevention, lower mortality, lower health costs, etc.

- Letting young adults stay on their parents health care until they are 26. We get it, that’s great, for many of you that’s the only thing you know you like about this law. Congrats that your parents had health insurance you were able to stay on, hope you can consider all the reasons you were glad you had insurance for more years and then apply that to all other Americans with this struggle.

- Tying Medicare payments to value: Ok. This is perhaps the most tectonic shift that the ACA caused in our system. This is also a really, really complicated part the law that I struggle to understand the details of so I’ll just give the simplest nutshell version. Prior to the ACA, docs, hospitals, etc got paid on a fee-for-service basis. Meaning that they got paid for each service they provided. This may seem like it makes sense except when you consider the incentives here. If I’m sick, providers are incentivized to run every test possible. Get an MRI because it might uncover something and why not. Do the same blood tests multiple times with each provider you see. If you have cancer, keep giving you chemo and radiation til the bitter end. Why would you prevent an epidemic of heart disease when you’ll get paid for every EKG you run and stint you insert? You get it. The ACA flipped this on it’s head. It said, “no, this makes no sense for our future or for caring for a whole population of people SO now you get paid for value. if you provide good care and do things to invest in the health of your population, you’ll get paid. If you run the same test 50 times, you’ll use up all your money and get penalized.” The shift to value-based payment is huge and so complex, but the idea is that more hospitals and providers get lump payments with which to take care of their patient population and they have to figure out the best way to make it work. They also have to meet certain quality criteria to keep getting paid. Including patient satisfaction. It’s a slow process, but by the end of 2016, 30% of Medicare payments were tied to value, which is no small potatoes, considering the complexity of implementing this and the fact that 10,000 people a day age into Medicare so there are lots and lots of people whose health care is paid for by Medicare.

No one read this far, but if you did, thank you. There’s a lot more this bill did. There is also a lot it didn’t do, but these are things to know before you make a decision about whether you want this repealed. If you ever wanna talk about it, let’s talk. Also, thank you President Obama for having the foresight and patience to try to make our health system a more humane and civilized entity.