13 Years After the ACA: Modernizing the Health Care Laws to Meet Changing Needs


Some of the most impactful laws passed in our country have needed to be revisited and fine-tuned to remain relevant to peoples’ lives. The Social Security Act, for instance, has been adjusted a number of times over the years to reflect changing demographics and longer life spans. The same is true for Medicare and Medicaid; both have been amended and modernized numerous times over the years to meet expanding health needs, including the addition of a prescription drug benefit for seniors.

The Affordable Care Act, considered by many to be perhaps the most consequential health care legislation since Medicare and Medicaid were enacted in 1965, marked its 13th anniversary yesterday.

The historic law has provided coverage to more than 30 million Americans and done a great deal of good to advance our nation’s health. The national uninsured rate has dropped from 15.5% to 8.6%, and Medicaid has been expanded in 39 states and Washington, D.C. Just this week, North Carolina became the latest state to expand Medicaid, expected to cover an additional 600,000 residents. Public opinion has mostly solidified in favor of the ACA; these days it enjoys support from the majority of Americans.

But 13 years and one pandemic later, the landscape has changed, and the laws and regulations that shape the U.S. health care system need to reflect that reality.

Paul Keckley, a consultant and managing editor of The Keckley Report, writes in a recent column that most people recognize the laws governing health care need “to be modernized based on trends and issues relevant to health care in 2030 and beyond.”

In recent years, we have seen things like the dramatic expansion of the use of artificial intelligence-based technologies, changes in consumer expectations around transparency, and a deeper appreciation of the social drivers of health and the science of overall well-being, to name but a few.

There have been other significant changes since 2010, when the ACA was signed into law. The pandemic didn’t exist. Telehealth and alternative sites of care were not yet prevalent, nor was the presence of private equity in healthcare delivery and financing.

What other kinds of trends and issues would an enhanced and modernized legislative and regulatory framework need to address? A partial list includes:

  • Having public payers cover the full cost of care. With an aging population saddled with complex, chronic conditions, the consequences of Medicare and Medicaid paying hospitals less than the costs of caring for patients will only grow larger, creating access barriers to the most medically complex care and stymie our ability to respond to emergencies like COVID-19. The Medicare Payment Advisory Commission’s recommendations to Congress are totally insufficient and out of touch with reality, given the rise in costs in caring for hospitals, particularly in regard to labor costs. The increase is simply not enough for the many hospitals and health systems that are in distress and struggling to keep their doors open. Put simply: the math doesn’t add up.
  • Leveling the playing field for non-traditional entrants into health care. While some could become responsible partners, others are deep-pocketed predators who refuse complex cases or those on Medicaid or people lacking insurance, and don’t have our regulatory requirements and accountabilities. We do not need entrants who place their own financial interests above patients, including by disintegrating the continuity of care and threatening the privacy and security of sensitive health information.
  • Putting an end to wasteful and dangerous administrative roadblocks, including excessive use of prior authorizations by commercial insurance plans that get in the way of the care that patients need and burden clinicians. While hospitals and health systems are focused on providing care, some insurers seem to be in the business of delaying or denying care.

The AHA strongly supported the ACA because it expanded coverage to millions of Americans and helped start the journey to transforming our health care delivery system to improve care and increase value.

Today, we believe that the public/private coverage framework and spirit of innovation at the heart of the ACA continue to provide us with a solid foundation on which to advance health in America.

However, as Keckley insightfully concludes in his column, “The trends and issues are new and complicated, requiring urgent forward thinking.” They also require action to sustain the future of access to quality health care services provided by America’s hospitals and health systems.


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