Thank you Dr. Purva Rawal for your synopsis on your recent publication. The following discusses major themes in context of current debates surrounding healthcare reform and the Affordable Care Act.


By: Purva Rawal, PhD

Adjunct Assistant Professor at Georgetown University
Principal at CapView Strategies

American healthcare is at a crossroads. The Affordable Care Act’s (ACA) passage in 2010 ushered in numerous changes to our health care system. While we are still understanding its impacts, Congress is pushing forward with an effort to repeal key parts of the law. The Congressional Budget Office’s (CBO) assessment of the House passed repeal and replace legislation estimated at leaving 23 million more Americans uninsured, and Medicaid funding would be reduced by $834 billion over the next decade. Despite a growing body of evidence on the ACA’s successes and areas where improvements are possible, the debate over our health care system seems mired in politics instead of progress forward.

The ACA has not only expanded coverage to millions, but it has mandated new consumer protections and benefits – including mental health and substance abuse services, and catalyzed widespread changes in healthcare payment to move from volume to value. As a result, systemic approaches to assessing and providing individualized care to individuals, such as the Transformational Collaborative Outcomes Measurement (TCOM) approach, are spreading more widely in healthcare. However, repeal and replace that does not assess the evidence of the law’s successes and failures could roll back coverage gains for millions of vulnerable Americans, weaken access to benefits that are essential for promoting health and well-being, and slow down the movement to value and population health. This post takes a closer look at some of the evidence and developments related to the ACA – away from all the politics.

The ACA’s Coverage Expansion and Insurance Market Reforms Are Improving Access to Coverage, Care, and Impacting Health

The ACA’s coverage expansion has increased health insurance coverage to an estimated 24 million individuals – approximately 19 million of whom were previously uninsured. The U.S. uninsured rate is at a historic low of 10.9 percent – compared to 17.1 percent in late 2013 before the ACA coverage expansion went into effect. In particular, Medicaid has played a significant role by expanding coverage to 12 million individuals.

Many of these gains have been made among low-income adults – including foster children that are allowed to remain on Medicaid until 26 years of age and parents. If legislation similar to the House-passed American Health Care Act (ACA) were to become law many of these individuals would become ineligible for coverage, and state Medicaid programs would see significant funding reductions as a result of capped Federal funding.

In addition to the coverage expansion, the ACA also mandated a number of reforms for the individual and small group markets to make access to coverage more equitable and to limit premium variation. Some of the most significant reforms included:

These reforms have been essential for guaranteeing access to insurance– especially to those with pre-existing conditions. These reforms, coupled with tax credits to offset the cost of coverage for eligible individuals and families, have made it possible to extend coverage to 10 million individuals through the regulated Marketplaces in 2017.

While major coverage reductions, funding cuts, and weakening of insurance market reforms are being debated in Washington, early evidence is demonstrating that insurance coverage is related to improved health status. A recent study published in Health Affairs, found that individuals that gained coverage under the ACA reported significant increases in a regular source of care, lower out-of-pocket costs, improvements on key health outcomes for chronic conditions, and better self-reported health. Demonstrating the impacts of the coverage expansion on low-income, vulnerable populations is critical to advancing evidence-based solutions that help more Americans gain coverage and improve their overall health.

ACA Is Transforming Behavioral Health and Emphasizing Outcomes Measurement

One of the ACA’s key goals was to move the healthcare system from paying for volume to paying for the value of services delivered. The Obama Administration set ambitious goals to shift health care payments in this direction. In 2015, the Department of Health and Human Services (HHS) announced goals to make 30 percent of Medicare payments to providers through alternative payment models, such as Accountable Care organizations (ACOs) and bundled payments, by the end of 2016, and 50 percent by the end of 2018. In 2016, the Administration announced it had met its 2016 goals early. States are also active in payment and delivery reform innovations. State Medicaid programs are driving payment and delivery reform, with initiatives such as health homes  focused on behavioral health.

The ACA – and in particular the Medicaid expansion – are bringing behavioral health into the spotlight as payers and providers are increasingly held accountable for patient expenditures and outcomes. While behavioral health needs have long been drivers of costs in Medicaid and in other markets, there has been little incentive to integrate those services into physical health settings until now. The ACA has increased access to these services, and is compelling commercial payers and large health systems to integrate and improve access to behavioral health services. Re-aligned incentives and increased access are creating new opportunities to address behavioral health – but premature repeal of the law could reverse these gains and trends.

Evidence Should Still Drive Decision-Making and Dialogue

The ACA has been one of the most politically and socially divisive issues the U.S. has faced in recent memory. Unfortunately, myths and claims about the law have dominated the public and policy dialogue on a complex law. Early evidence shows significant coverage gains, increased access to services – especially behavioral health, improvements in health, and a greater emphasis on outcomes measurement. While the debate in Washington DC could lead to major steps backward despite these gains, a continued commitment to research, building an evidence-base, and communicating results and opportunities for improvement to policymakers are critical to advancing the transformation providers and experts know is necessary and achievable across populations and systems.

Purva Rawal, PhD is an Adjunct Assistant Professor at Georgetown University, a Principal at CapView Strategies, and author of The Affordable Care Act: Examining the Facts.


For questions about this post or for more information on Dr. Rawal's work, reach out directly at

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