In a Special Communication published in JAMA, President Obama assesses the Affordable Care Act’s progress and recommends additional steps for elected officials to take to improve US healthcare. He notes that when he took office, more than 1 in 7 Americans lacked insurance coverage. Since the ACA’s adoption, the uninsured rate has declined by 43%. Having 29 million people uninsured in this country is still shameful, but it’s a big improvement over the 49 million uninsured in 2010.

In addition to reducing uninsurance, Obama notes, “The law has also greatly improved health insurance coverage for people who already had it.” Insurers can no longer decline to cover certain kinds of care (like mental health or maternity care), charge substantially higher premiums to individuals based on health history or sex, or limit how much they’ll spend on a single person’s care during a year or a lifetime. Enrollees no longer have to pay cost-sharing for preventive care, and there are limits to how much a person can be required to spend out-of-pocket on healthcare in a single year.

The ACA also began the torturous task of shifting this country’s dysfunctional healthcare system from one that pays primarily based on the quantity of care to one that rewards high-quality care. Obama explains (references ommitted):

Most importantly over the long run, the ACA is moving the health care system toward “alternative payment models” that hold health care entities accountable for outcomes. These models include bundled payment models that make a single payment for all of the services provided during a clinical episode and population-based models like accountable care organizations (ACOs) that base payment on the results health care organizations and health care professionals achieve for all of their patients’ care. The law created the Center for Medicare and Medicaid Innovation (CMMI) to test alternative payment models and bring them to scale if they are successful, as well as a permanent ACO program in Medicare. Today, an estimated 30% of traditional Medicare payments flow through alternative payment models that broaden the focus of payment beyond individual services or a particular entity, up from essentially none in 2010. These models are also spreading rapidly in the private sector, and their spread will likely be accelerated by the physician payment reforms in MACRA.

Growth in healthcare costs has slowed since the ACA’s passage, although Obama acknowledges that the recession played a role in this.

Looking ahead, Obama writes that “further adjustments and recalibrations will likely be needed” in the insurance marketplaces where people without employer-sponsored coverage can purchase coverage. This means we’ll continue to see premiums rise, and some people will struggle to afford either their premiums or the cost-sharing their plans require. To help those struggling with healthcare costs, Obama urges the 19 states that haven’t yet accepted the Medicaid expansion to do so, and suggests that lower-than-expected ACA coverage expenditures makes it feasible to offer more financial assistance to families who still struggle with insurance or healthcare costs. He also lists ways to address high prescription-drug costs, including giving the federal government authority to negotiate prices for some high-cost drugs.

Obama also notes that 88% of those who purchased marketplace coverage live in counties with at least three insurance issuers, and that competition can keep costs lower than they might be otherwise. He suggests that a “Medicare-like public plan,” which Congress considered when drafting the ACA, could be especially beneficial to the 12% of marketplace enrollees who live in areas with only one or two issuers, writing, “I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited.”

In the “Lessons for Future Policy Makers” section, the President’s frustration with Congressional Republicans is evident:

The first lesson is that any change is difficult, but it is especially difficult in the face of hyperpartisanship. Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported. For example, they supported a fully funded risk-corridor program and a public plan fallback in the Medicare drug benefit in 2003 but opposed them in the ACA. They supported the individual mandate in Massachusetts in 2006 but opposed it in the ACA. They supported the employer mandate in California in 2007 but opposed it in the ACA—and then opposed the administration’s decision to delay it. Moreover, through inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation, Republicans undermined ACA implementation efforts. We could have covered more ground more quickly with cooperation rather than obstruction. It is not obvious that this strategy has paid political dividends for Republicans, but it has clearly come at a cost for the country, most notably for the estimated 4 million Americans left uninsured because they live in GOP-led states that have yet to expand Medicaid.

Even so, he finishes on an optimistic note, writing, “I am as confident as ever that looking back 20 years from now, the nation will be better off because of having the courage to pass this law and persevere.”

I don’t doubt that 20 years from now, most of us will be very glad the ACA passed. I hope we’ll also be able to say that we narrowed the gap between the most and least fortunate — that those with incomes under the poverty level will all have access to Medicaid, that living in certain counties won’t mean individual insurance plans are far more expensive, and that those diagnosed with cancer or other serious illnesses won’t have to wonder if they’ll be able to afford treatment. This all depends on who gets elected in November.