A Critical Analysis of Obamacare: Affordable
Care or Insurance for Many and Coverage for
Few?
Authors: Manchikanti Laxmaiah 
Published: January 2020

The Affordable Care Act (ACA), of 2010, or Obamacare, was the most monumental change
in US health care policy since the passage of Medicaid and Medicare in 1965. Since its
enactment, numerous claims have been made on both sides of the aisle regarding the ACA’s
success or failure; these views often colored by political persuasion.
The ACA had 3 primary goals: increasing the number of the insured, improving the quality
of care, and reducing the costs of health care. One point often lost in the discussion is the
distinction between affordability and access. Health insurance is a financial mechanism for
paying for health care, while access refers to the process of actually obtaining that health
care. The ACA has widened the gap between providing patients the mechanism of paying for
healthcare and actually receiving it.
The ACA is applauded for increasing the number of insured, quite appropriately as that has
occurred for over 20 million people. Less frequently mentioned are the 6 million who have lost
their insurance. Further, in terms of how health insurance is been provided, the majority the
expansion was based on Medicaid expansion, with an increase of 13 million. Consequently,
the ACA hasn’t worked well for the working and middle class who receive much less support,
particularly those who earn more than 400% of the federal poverty level, who constitute
40% of the population and don’t receive any help. As a result, exchange enrollment has
been a disappointment and the percentage of workers obtaining their health benefits from
their employer has decreased steadily. Access to health care has been uneven, with those on
Medicaid hampered by narrow networks, while those on the exchanges or getting employer
benefits have faced high out-of-pocket costs.
The second category relates to cost containment. President Obama claimed that the ACA
provided significant cost containment, in that costs would have been even much higher if the
ACA was not enacted. Further, he attributed cost reductions generally to the ACA, not taking
into account factors such as the recession, increased out-of-pocket costs, increasing drug
prices, and reduced coverage by insurers.
The final goal was improvement in quality. The effort to improve quality has led to the creation
of dozens of new agencies, boards, commissions, and other government entities. In turn,
practice management and regulatory compliance costs have increased. Structurally, solo and
independent practices, which lack the capability to manage these new regulatory demands,
have declined. Hospital employment, with its associated increased costs, has been soaring.
Despite a focus on preventive services in the management of chronic disease, only 3% of
health care expenditures have been spent on preventive services while the costs of managing
chronic disease continue to escalate.
The ACA is the most consequential and comprehensive health care reform enacted since
Medicare. The ACA has gained a net increase in the number of individuals with insurance,
primarily through Medicaid expansion. The reduction in costs is an arguable achievement,
while quality of care has seemingly not improved. Finally, access seems to have diminished.This review attempts to bring clarity to the discussion by reviewing the ACA’s impact on affordability, cost containment and quality
of care. We will discuss these aspects of the ACA from the perspective of proponents, opponents, and a pragmatic point of view.
Key words: Affordable Care Act (ACA), Obamacare, Medicare, Medicaid, Medicare Modernization Act (MMA), cost of health
care, quality of health care, Merit-Based Incentive Payments System (MIPS)