The ACA Turns 6: Reflections from California for the 2016 Presidential Election Year

The Affordable Care Act, President Obama’s signature achievement, turns six today, March 23, in the heat of the most contentious and divisive presidential campaigns in recent memory. In the presidential race we see the usual partisan divide with the Democrats wanting to either build on it (Clinton) or move to single-payer health care (Sanders), and the Republicans vowing to repeal and replace it with “something that’s going to be terrific” or not replace it at all.

Partisanship apparently comes first in candidates’ positions on the Affordable Care Act, ignoring the law’s results or objective markers of success. The same is true for some members of the California Congressional Delegation, despite the state’s stellar results from the ACA. Fourteen members voted to repeal the ACA when the option came before them, all 61 times.

In every state across the union we find ample reasons to celebrate, rather than lament, the Affordable Care Act. And in California and a handful of other states that have implemented the ACA in good faith and gone further to address local priorities for reform, there is even greater cause for celebration backed up by a solid body of result.

ACA Results at the National and State Level

  National Level Results of ACA State Level Results


More than 17.6 million uninsured people gained coverage, while keeping insurance affordable for countless others.

76 million Americans have gained preventive services benefits since the ACA was enacted.










The number of uninsured in California has dropped by more than half.

Nearly 1.6 million Californians have selected or automatically renewed quality, affordable health care coverage in Covered California. Of these, 90% qualified for a premium tax credit. The younger demographic (under age 35), which balanced out the risk mix and thus stabilizes cost, is growing as a proportion of new enrollees, comprising 33% of plan selections.

Since California implemented the Medicaid expansion one year ahead of most other states, nearly 4 million Californians have gained Medicaid or CHIP coverage.More than 9 million Californians have access to cost-free preventive services.

The removal of lifetime limits on health benefits has benefited another 12 million+ Californians, and 16+ million Californians need no longer worry about discrimination for pre-existing conditions.










On another key objective of the law to slow the growth in premium costs, the law is working as intended. A recent analysis of 2016 premium changes in 10 states found that the cost of the most popular silver benchmark plan was on average 4.4% higher in 2016. Even on issues of importance to Republicans, like slowing the growth in overall health care spending, the law is showing promising signs. By 2013, U.S. health care spending had reached its slowest rate of growth in 50 years, continuing a progressive decline that began in 2009.  See more cost savings under quality below. As an “active purchaser” insurance marketplace, Covered California has successfully slowed growth in premium costs to 4% in 2013, which is even lower than the 2012 rate of 4.2%.  Between 2011 and May 2014, CalPIRG has estimated that the state’s aggressive rate review process had saved the state an estimated $349 million, more than one third of the total saved nationally.  Thanks to the “medical loss ratio requirements of the ACA (which are applied across the entire California insurance market, 490,052 Californians with private insurance coverage benefited from $11,902,850 in refunds from insurance companies, an average refund of $39 per family.










The ACA has been testing new innovative models of care delivery like ACOs (Accountable Care Organizations), and already these have served 7.8 million Medicare beneficiaries. ACOs participating in the Shared Savings Program have improved on 27 of 33 quality measures. Altogether the Medicare ACO models have resulted in a net savings of $411 million.  From 2010 to 2013 the Medicare ACOs have reduced the rate of hospital-acquired conditions by 17%, resulting on $12 billion in savings and sparing 50,000 lives. That’s just one example. Deeper savings and better outcomes are expected over time from the other QI initiatives sponsored by the ACA, including expansion of electronic health records, the Million Hearts Cardiovascular Disease Risk Reduction measure, access to cost and quality information, and
“Independence At Home” initiatives that allow people to age less expensively at home instead of nursing homes (learn more here).
Through its DSRIP (Delivery System Reform Incentive Payments) program, the state’s public health care systems are actively transforming the way care is delivered and paid for. Through this program and its successor program, PRIME, the public health care safety net has a solid foundation for continuous delivery system improvements that will boost outcomes for the most vulnerable patients while saving state and federal dollars (learn more here).

Covered CA, the fulcrum of state health reform implementation, is committed to even more far-reaching delivery system reforms that will address the “quadruple aim” of cost, quality, better outcomes, and equity (see this summary for details) through these areas: improving care, use of data, reducing disparities, promoting development and use of care models, hospital quality, population health and at-risk enrollee support; patient-centered information and communication, promoting higher value care, and accreditation of plans.

With those results to show for the first six years of implementation, it is no wonder that opinion polling has started to shift in favor of the law or building upon it.

The most recent Kaiser tracking national poll finds a shift towards keeping the law intact, with the largest share of respondents saying (36%) lawmakers should build upon the ACA to improve affordability and access to care, rather than replace it. Compared to earlier Kaiser polls, fewer Americans (24%) want a single government plan like single-payer, though a significant number still do. But by far the smallest group surveyed want to repeal it outright (16%) or repeal and replace it with a Republican alternative (13%).

In California the law is even more popular, with 62% in support of the law and only 33% opposed (2015 California Wellness Foundation field poll). The state’s results-to-date begin to explain why the law remains popular in the Golden State.

With that background, we ask why 14 members of California’s Congressional Delegation persist in their promise to repeal the ACA. If the ACA were actually repealed, it would cost the state an estimated $13 billion to replace the revenues for the health system on which we all rely. If there is any state that should stop the partisan showmanship, it’s California, which has the most to lose from repeal. If we can make a wish before blowing out the 6th birthday candles, that is our wish.