Click here for a transcript of the episode.

President Joe Biden released his budget proposal for 2023 this week, and it calls for a nearly 27% increase in funding for the Department of Health and Human Services. That includes $28 billion for the Centers for Disease Control and Prevention to implement a preparedness program for future pandemics and $40 billion for HHS to invest in making vaccines and other medicines.

Also, the FDA and the CDC authorized a second booster shot for most people 50 and older. But federal officials offered little advice to consumers about who might need that shot and when.

This week’s panelists are Mary Agnes Carey of KHN, Amy Goldstein of The Washington Post, Jennifer Haberkorn of the Los Angeles Times, and Rachana Pradhan of KHN.

Among the takeaways from this week’s episode:

• Biden’s advocacy for funding preparations for a future pandemic reinforces his sense of urgency in bolstering the public health infrastructure, but whether Congress will take that track is unknown. Already, some lawmakers are balking at the administration’s request for more money to help fund additional covid-19 testing and vaccine efforts.
• A bipartisan group of senators has been meeting in the past several days hoping to find a compromise to restore funding for testing and vaccinations. Republicans have complained that earlier appropriations for covid have been spent too recklessly and that there isn’t enough transparency about where it has gone. They would like some of the funds that haven’t been spent to be clawed back. There is no indication yet that the group of senators has a plan for moving forward, but the upcoming spring recess for Easter and Passover may provide a deadline that helps focus the debate.
• The administration originally sought more than $20 billion for testing and vaccines. Congress appeared ready to spend about $15 billion before hitting the impasse. Some reports suggest that the Senate negotiators are talking about $10 billion, which may provide funding for only several months.
• The Centers for Medicare & Medicaid Services also announced this week that a new analysis shows the growth in health spending in the U.S. has slowed.
• Millions of Americans are expected to lose Medicaid coverage once the covid emergency ends and states will be able to disenroll people who no longer meet eligibility requirements. Advocates warn that some of those people will not move to other coverage options, such as insurance offered on the Affordable Care Act’s insurance marketplaces.
• One priority of the ACA was to help drive down health costs, and the law established an innovation center to fund projects looking for ways to do that. Experts at the time suggested that value-based care could make a difference, and the center has made that a guiding principle in its research. But there is little evidence so far that such efforts are producing meaningful results.

Also this week, Julie Rovner interviews KHN’s Julie Appleby, who reported and wrote the latest KHN-NPR “Bill of the Month” installment about a very expensive air ambulance ride. If you have an outrageous medical bill you’d like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Mary Agnes Carey: ,” by David Owen

Amy Goldstein: Stat’s “,” by Lev Facher

Jennifer Haberkorn: The New York Times’ “” by Christina Jewett

Rachana Pradhan: The Washington Post’s “‘’” by William Wan

Also discussed on this week’s podcast:

The Wall Street Journal’s “,” by Philip Krause and Luciana Borio

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on , , , or wherever you listen to podcasts.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

ACOs were expected to save the government , according to the Congressional Budget Office.

It hasn’t come anywhere close.

On Thursday, the Trump administration proposed , which was designed to encourage doctors and hospitals to work together to coordinate care by reducing unnecessary tests, procedures and hospitalizations. The move could dramatically scale back the number of participating health providers.

Administration officials say ACOs have led to higher Medicare spending.

The announcement was just the latest in a steady drumbeat of moves by Trump administration officials to unwind health policies set in place by the Obama administration.

Medicare ACOs began in 2012 and today enroll more than 10 million beneficiaries. If they provide care for less than certain cost targets — while meeting quality of care standards — then they get to share in any of the savings. Commercial insurers and Medicaid have also adopted ACOs in the past decade.

About of the 561 Medicare ACOs are set up so that they are not at risk of losing money from Medicare. They can share in any savings they achieve. The rest are in a model where they can gain a higher share of savings, but also risk paying back money to Medicare if they do not meet their savings targets. Those ACOs have been more successful in saving money, Medicare officials said.

The Medicare program said it would phase out its no-risk model beginning in 2020.

A recent showed 70 percent of ACOs would rather quit than assume such financial risk.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said it’s wrong to have ACOs that can only make profits but not risk any losses. “We want to put the accountability back into Accountable Care Organizations,” she said during a briefing with reporters.

Existing ACOs will have one year to switch to a model accepting financial risk. New ACOs will have two years.

Currently, ACOs have up to six years to shift to a model where they share in financial risk.

These and other proposed changes would save Medicare $2.2 billion over the next decade, Verma said.

The proposal drew rare praise from a former Obama administration official. Andy Slavitt, who once headed CMS, tweeted: “CMS is proposing changes to Medicare pay for value (ACO) models. … At first look, they look positive to me.”

CMS estimated that its new policy would lead to a drop of about 100 ACOs by 2027.

Industry observers say that prediction seems modest at best.

“That does not seem too realistic,” said Ross White, manager of the Center for Healthcare Regulatory Insight at KPMG, a large consulting firm. “This is going to come as quite a shock to a lot of current participants, although the administration has been sending these signals for several months. … It definitely seems like they are trying to ratchet down and squeeze the dollar savings out and not have participants in it for the wrong reasons.”

Clif Gaus, the CEO of the National Association of ACOs, blasted the proposal, saying it will “upend the ACO movement” and introduces “many untested and troubling policies.”

CMS is “pulling the rug out from ACOs by redoing the program in a short time frame,” he said.

He added that the “likely outcome will be that many ACOs quit the program, divest their care coordination resources and return to payment models that emphasize volume over value.”

Tom Nickels, executive vice president of the American Hospital Association, also criticized the new ACO rules. “The proposed rule fails to account for the fact that building a successful ACO, let alone one that is able to take on financial risk, is no small task; it requires significant investments of time, effort and finances.”

Under the new plan, CMS also wants to require doctors in ACOs to inform their patients that they are in an ACO. That has not occurred previously, because unlike HMOs, ACOs do not restrict which providers they can see.

Verma, who has repeatedly said unleashing the free market principles will help control costs and improve quality, said ACOs are driving more hospitals and doctors into mergers, which leads to higher costs.

“We want to work with ACOS that are serious about delivering value. We can no longer run a program that is losing money for taxpayers,” she said.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

But her health is not high on the 41-year-old woman’s priority list.

“I have a lot going on,” said the unemployed mother of five who lives in a homeless shelter. She said it’s a struggle just to get herself and children through each day.

Her health bills are covered by Medicaid, the state-federal health insurance program for the poor. That’s a relief for her, she said. But state officials say Medicaid is busting Minnesota’s budget, particularly with patients like Dowland and its system of paying hospitals for each admission, ER visit and outpatient test.

To ease that financial strain, Minnesota is at the forefront of a growing number of states testing a Medicaid payment system. It rewards hospitals and physician groups holding down costs by keeping enrollees healthy.

Under this arrangement, those health care providers are asked to do more than just treat medical issues such as diabetes and heart disease. They are called on to address the underlying social issues — such as homelessness, lack of transportation and poor nutrition — that can cause and exacerbate health problems.

It’s why North Memorial arranged for a community health worker and paramedic to meet Dowland on a recent weekday at a day care center for homeless families. They advised her on how to take her insulin, prodded her to use a patch to quit smoking and helped her apply for Social Security disability payments and food stamps.

“This is nice to have someone who I can talk to about everything in my life and give me access to the community resources I need,” said Dowland, who added that she puts off her own health needs in order to care for her children and look for housing and a job. “I appreciate the help because, at the clinic, the doctor doesn’t have time for this.”

North Memorial is among 21 health systems in Minnesota participating in this new model of care, called accountable care organizations. ACOs get to share in money they save Medicaid by keeping spending under a budget and by reaching quality targets, such as averting hospital-acquired infections and controlling patients’ blood pressure and asthma.

The shift toward ACOs is occurring with Medicare and employer-sponsored insurance, too. But for Medicaid programs, it presents unique challenges. Medicaid enrollees, by definition, are low-income. Many have little experience navigating health systems and large numbers are homeless or dealing with mental health problems, conditions that can lead to difficulties in encouraging healthy behaviors.

“The goal [of ACOs] is really exciting to make health systems more responsive to what people need to be healthy,” said Ann Hwang, director of the center for consumer engagement and health innovation at Community Catalyst, a Boston-based consumer advocacy group. “But the jury is still out as to whether they are really moving the needle in addressing social services such as transportation, housing and food insecurity — the things we know affect people’s ability to be healthy.”

Nationwide, a dozen states are experimenting with Medicaid ACOs and 10 more are making plans for them.

About half of Minnesota’s 1 million Medicaid recipients are in ACOs, which officials said saved the state $213 million since 2013. Hospitals and doctors received $70 million of that.

In addition to North Memorial, other participating health systems include the Mayo Clinic and Hennepin Healthcare, the state’s largest safety-net provider based in Minneapolis.

‘Going To Where The Patient Is’

For giant health systems that for years have competed by adding the latest technology or building sleek facilities, the ACOs are a huge shift. In effect, the ACOs push hospitals to address patients’ problems before they end up in the ER or operating rooms.

“We are learning to have to do a better job of going to where the patient is … as we now realize we are responsible for the patient when they are engaged with us and when they are not here,” said Robert Stroebel, who helps leads the ACO effort at Mayo Clinic.

So far, the model isn’t proving to be a panacea.

In six states using ACOs, a March federal study in found, Medicaid enrollees received more primary care services — such as doctor visits — but the program did not reduce hospital visits in most states or lower costs.

“Changing provider and beneficiary behavior may take more time than the few years this report covers,”

Minnesota’s experience demonstrates the challenges of changing to a new Medicaid payment system. In 2016, the latest year for which data are available, only six of the 16 ACOs were eligible to share in cost savings.

But Marie Zimmerman, Minnesota’s Medicaid director, noted the state’s program has seen a 7 percent cut in ER visits and a 14 percent reduction in hospital stays in areas where health providers participate in an ACO.

“Medicaid is 20 percent of Minnesota’s population, and we have to care about getting the best deal and the long-term fiscal ability of the program and not cutting eligibility and provider rates and benefits to show sustainability,” she said.

Struggle To Change Behaviors

The switch to ACOs accelerated efforts by hospitals and physician groups to attack so-called social determinants of health, such as the lack of stable housing and poor nutrition. But providers still struggle to change patients’ behaviors, particularly helping those with addiction and mental health problems, according to interviews with officials at several ACOs.

Doctors, nurses and social workers at Hennepin dealt with that head-on during a recent routine review of their patients. When they came to a 58-year old man suffering from alcoholism, anxiety and heart problems and living in a homeless shelter, they noted how they couldn’t get him into a primary care clinic and saw him only during frequent hospital admissions.

“Best we can hope for him is if we can facilitate a safe ending,” said Dr. Rachel Silva, a Hennepin internist, acknowledging that despite their best intentions, health providers likely would not be able to prevent his early death.

Even with teams of nurses, social workers and community health workers, Hennepin officials say they struggle to keep up with many Medicaid enrollees who have addiction problems, and many patients still go to the ER out of habit or convenience rather than the organization’s primary care clinics, which are as close as across the street.

Yet, there are success stories, too. The Mayo Clinic has started a community health worker program to help at-risk patients connect to social services such as housing and transportation.

Nancy Zein, 47, a Medicaid recipient who uses the Mayo Clinic, said having weekly meetings with community health worker Tara Nelson has been life-changing for her and her mother, who is also on Medicaid.

“She’s been a godsend,” said Zein, who noted how Nelson helped her get Social Security disability payments and her mom find affordable housing for disabled adults, as well as get both enrolled for food stamps.

“It’s made such an impact on our health,” Zein said. “My mom has depression issues, and with Tara helping us with housing, it helped her depression.”

With the opportunity to share in financial savings, North Memorial has hired additional community paramedics to visit high-risk patients. Mayo Clinic has added community health workers to help patients find housing and transportation and nurses to make home visits to patients after leaving the hospital. Hennepin set up special clinics for the most challenging Medicaid patients and sends doctors to care for patients in homeless centers, jails and the county’s mental health center — to reach people who may need help even before they are likely to end up in their ER and on Medicaid.

Nearly 20 percent of Hennepin’s adult Medicaid ACO members are homeless. In the past four years, social workers and other staff have helped more than 500 of their Medicaid patients — including in the ACO — get into public housing.

Cuts For Managed-Care Companies

The ACO model has raised concerns among managed-care companies that Minnesota and other states have used for decades to control Medicaid spending. Those companies get a monthly fee from Medicaid for each enrollee and often require those patients to seek care with doctors and hospitals that have contracts with the managed-care firm. The companies profit if they spend less on care than they receive in the state allotment.

“We are aligned with the goals … to explore innovation and provide better delivery of care,” said Scott Keefer, vice president of Minnesota Blue Cross and Blue Shield of Minnesota, which has 300,000 Medicaid members. But, he added, much of the ACO savings cited by state officials are dollars taken from managed-care company profits.

His health plan lost more than $200 million from Medicaid operations during the past two years, partly because it had to pay part of its state funding to ACOs.

“We are not magically saving money. … We are moving the financial deck chairs around,” he said.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

First, it’s likely that fewer patients would be able to pay their hospital bills, health policy analysts say, so the institutions would be stuck with that bad debt, as they were before Obamacare.

“If the Medicaid expansion goes away wholesale, and things go back to the way they were before this expansion was in place, a lot of those hospitals would see an increase in their uncompensated care costs,” said , an analyst with the Kaiser Family Foundation. The American Hospital Association estimates that hospitals across the U.S. could more than $160 billion from the reduction in Medicaid revenue and the increase in unpaid medical bills. (KHN is an editorially independent program of the foundation.)

Then there’s this: The ACA has used financial incentives to encourage hospitals to experiment with ways to improve their care of patients, while reducing health care’s cost. That sort of experimentation has included a sizable upfront investment by many hospitals.

“We have now more than 20 different programs,” said , an internist and medical director of the Mass General Physicians Organization. “Video visits, electronic consultation with specialists, home hospitalization, [and] programs for patients with diabetes and heart disease. I would be worried that a repeal of the ACA would undermine our ability to invest in services for our patients.”

Ferris acknowledged that most of those experiments saved money. But they need more time to work out the kinks safely, he said.

“One of the things that it’s difficult for people outside of health care to appreciate — particularly politicians — is how long it takes to make significant improvements in the delivery of care,” Ferris said. “You have to be very careful when you make changes.”

Ferris said the threatened repeal of the ACA makes him worry “that the progress we’ve made over the past five years would be threatened.”

Many other have invested in accountable care organizations — often overhauling their medical records systems, hiring staff and creating new services. , head of a large hospital chain called in Rhode Island, said he, too, worries about the future of his ACO, .

“I think, if there’s a real change in direction away from these alternative payment models, we will be assuming risk to care for a population,” Keefe said. “We have invested enormously to be successful in this area.”

But these seismic changes in the way hospitals do business were predicated, he adds, on long-term support from the federal government — support that might disappear if the ACA is repealed.

This story is part of a partnership that includes , and Kaiser Health News.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Under the 10-year partnership unveiled Thursday, UnitedHealth Group Inc. and the UC system will form an accountable care organization that will be offered to large, self-funded employers statewide. In accountable care organizations, or , physicians, hospitals and an insurer work together to coordinate care, control spending and share savings.

The for-profit insurer will also open a research lab in the San Francisco area early next year offering researchers at the state-run health system access to a huge national database of patient records.

The collaboration comes as hospital systems and insurers are under increasing pressure from employers, government health programs and their competitors to forge new alliances aimed at improving care and cutting costs. It also reflects the growing importance of data mining to achieve those goals by identifying disease earlier and finding more effective treatments.

The deal marks UnitedHealth’s continued interest in growing its California business despite its decision in May to leave the state’s health insurance exchange.

The company’s Optum unit was recently awarded a five-year contract to manage pharmacy benefits for the California Public Employees’ Retirement System, and UnitedHealth is expanding its presence in Medi-Cal, the state’s Medicaid program. The company said it now serves more than 3.5 million Californians.

The UC system runs five academic medical centers in Los Angeles, San Francisco, San Diego, Irvine and Davis, including hospitals, medical groups, clinics and other outpatient facilities. They will continue to work with other insurers such as Anthem Inc. and Blue Shield of California as network providers and in other ACOs.

But UnitedHealth offered several advantages compared to its rivals in terms of data-mining capabilities and administrative support for hospitals and physician offices through its consulting unit, said David Kraus, chief contracting and clinical strategy officer for the UC Health system.

“What was unique about UnitedHealth is they are more than just a health plan,” Kraus said. “This collaboration helps us advance things quicker.”

Kraus said the university system and UnitedHealth want to learn from the mistakes of earlier ACOs and offer employers a more centralized approach that can tap into real-time data as patients move through the health care system.

“A lot of employers have a physical health product unrelated to a mental health product unrelated to their wellness program, which is completely unrelated to the pharmacy benefit. We think it needs to be all together, and we get to build this ACO from the ground up,” Kraus said.

The financial terms of the partnership weren’t disclosed. Kraus said a joint governing board will establish the specific financing for individual projects and determine how much each organization contributes.

“We will look at pilots and talk about which ones to invest in and where,” Kraus said. “It could be 80 percent-20 percent or 60-40. We haven’t boxed ourselves into a preordained structure.”

Steve Valentine, vice president and West Coast consulting leader at the health care firm Premier Inc., said the deal brings together two highly regarded organizations, but he said some employers chafe at the high cost of UC facilities.

“UC has to address its whole cost structure,” Valentine said. “They tend to be more expensive so they will need to address pricing to be competitive.”

UnitedHealth is playing catch-up in a crowded market. Anthem, the nation’s second-largest health insurer, has been the dominant player in California for self-funded employers. In that scenario, large employers have the financial resources to pay their own medical claims. They hire an insurer to administer the health plan and create a provider network.

Anthem had a 37 percent share of the 6.4 million Californians covered by the self-funded market in 2014, according to data from the California Health Care Foundation. Cigna Corp. was second with 24 percent market share, followed by UnitedHealth and Blue Shield of California at 13 percent apiece. (California Healthline is an editorially independent service of the California Health Care Foundation.)

HMO giant Kaiser Permanente has a smaller presence in the state’s self-funded market. In the fully insured market for large employers, Kaiser Permanente leads the state with a nearly 50 percent share.

Under the new deal, the insurer will establish an office in the San Francisco area for OptumLabs. UnitedHealth founded OptumLabs, a collaborative research center, with the Mayo Clinic in 2013 and the headquarters is in Cambridge, Mass. Other partners such as AARP, Harvard Medical School and Pfizer later joined the research effort.

OptumLabs said it will provide UC researchers and physicians access to one of the nation’s largest databases of medical claims, although it will not be publicly available and patients’ identities will not be revealed. It contains claims information on more than 150 million people going back two decades. It also includes electronic medical records on another 50 million patients.

In one research project, OptumLabs has examined whether scanning the narrative portion of electronic medical records could indicate which patients are at risk of developing Alzheimer’s disease rather than waiting for physician tests down the road.

“There is so much depth of knowledge in the University of California system and we are certain when some of that expertise is applied to the data at OptumLabs it will really move us forward,” said Dr. Paul Bleicher, chief executive officer of OptumLabs. “We work on the most difficult problems in health care.”

The two organizations also want to use the California office of OptumLabs to lure young data scientists into the medical field rather than lose them to game developers or social media in Silicon Valley.

“Everybody is struggling with the fact that Facebook, Google and other tech companies are very attractive and obvious targets for new graduates coming out,” Bleicher said. “This will help bring in UC students to work on our data.”

This story was produced by , which publishes , an editorially independent service of the .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The move, announced Tuesday, marks the expansion of Boeing’s direct-contracting approach, which it has already implemented in recent years in Seattle, St. Louis and Charleston, S.C.

Other large employers are also pursuing this idea in regions where they have big concentrations of workers. In some cases, they refer employees to nationally top-performing hospitals for select surgeries.

MemorialCare Health System said Chicago-based Boeing selected it from a group of bidders for the five-year contract in Southern California, where the company has roughly 37,000 employees and dependents. Financial terms weren’t disclosed.

“More employers are interested in moving in this direction,” said Barry Arbuckle, chief executive of the MemorialCare Health System, based in Fountain Valley, California. “It reflects the desire of these employers to participate in bending the cost curve for health care, and it allows the provider to have a more unfettered relationship with the employer and employees.”

The new health plan will be offered to Boeing workers in Southern California during open enrollment this fall alongside some existing options, including a Kaiser Permanente HMO. Coverage starts Jan. 1.

MemorialCare, a large integrated health system spanning Los Angeles and Orange counties, partnered with other hospital systems and physician groups to create a broader network.

The partners include UC Irvine Health, Torrance Memorial Health System and PIH Health.

This MemorialCare Health Alliance will include nine hospitals, about 2,400 physicians and other providers, as well as 71 surgery centers, urgent-care facilities and other freestanding clinics.

“MemorialCare and its partners have a long track record of health care leadership and innovation in Southern California, as well as a strong market presence,” Jeff White, Boeing’s director of health care strategy, said in a statement. “Creating these partnerships is one of the innovative ways we are managing our health care programs to improve quality and efficiency.”

Boeing and other self-insured employers have typically hired health insurance companies to contract with hospitals and doctors and design their employee benefits. As medical costs kept escalating, employers and health insurers often narrowed their networks to negotiate lower rates and shifted more of the costs onto workers through higher deductibles.

Direct contracting is seen as another way to potentially save money while improving care and patient satisfaction.

In these contracts, health systems usually take on the financial risk of managing the health of a large population. The provider groups are often organized as accountable care organizations, in which physicians and hospitals share the financial responsibility for coordinating care and avoiding unnecessary spending.

An ACO is a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending.

This MemorialCare ACO designed for Boeing must meet numerous performance measures of quality, access and savings, Arbuckle said.

The Boeing contract “allows us to earn certain incentives or, if we don’t meet certain criteria, incur a loss on that particular aspect,” Arbuckle said. “There is no incentive to keep people in the hospital and go to multiple specialists. For us, this is where health care needs to go.”

Steve Valentine, vice president and West Coast consulting leader at health-care firm Premier Inc., said MemorialCare was a logical fit for Boeing, but plenty of health systems will be competing for these types of contracts.

“Most health systems have been building up their infrastructure to do exactly this kind of relationship,” Valentine said.

MemorialCare won’t have to handle all of the administrative chores of an insurer. Boeing uses its national insurance administrator, Blue Cross and Blue Shield of Illinois, to process claims for its direct contracts.

Boeing will offer workers several incentives to choose this new provider-backed health plan in California.

Enrollees will have no copays for primary-care visits. They will get full coverage for generic drugs and the freedom to choose specialists within the network without a referral. Emergency care will be covered as in-network even if it’s received outside MemorialCare. Boeing will also offer increased contributions to workers’ health savings accounts.

In other examples, Intel Corp. contracted directly with a major health system in New Mexico, where it has several thousand employees.

Retailers Wal-Mart and , striking deals with select hospitals across the country for bundled prices on specific surgeries. The companies steer workers to those hospitals.

This story was produced by , which publishes , a service of the .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

“Our health care is a horror show,” said GOP candidate Donald Trump at the Republican debate in South Carolina Dec 15. Texas Sen. Ted Cruz, winner of the Iowa caucuses, said at the that the health law has been “a disaster. It is the biggest job-killer in our country.”

Democrats largely support the law, but even they can’t agree on how to fix its problems. Hillary Clinton said at the Jan. 25 that she wants to “build on the ACA. Get costs down, but improve it, get to 100 percent coverage.”

In some cases candidates are bending the truth. But in general, both praise and criticisms of the law are accurate. That’s because the health law is so big and sweeping that it has had effects both positive and negative.

Here is a brief guide to some things the health law has — and has not — accomplished since it was signed by President Barack Obama in 2010.

CLAIM: The law has increased the number of people with health insurance coverage.

This is true, no matter what measure you use. The official and polling firm both found substantial drops in the percentage of people without health insurance after the majority of the law’s coverage expansions took effect in 2014.

COUNTER-CLAIM: There are still millions of Americans who don’t have insurance.

This is also true. Even though approximately 90 percent of Americans now have insurance, that remaining 10 percent amounts to .

Millions aren’t eligible for coverage under the law because they’re not in the U.S. legally. Another 3 million are in the so-called “,” meaning they would be eligible for Medicaid under the ACA except their states opted not to accept the expansion after the Supreme Court effectively ruled the expansion optional.

Still others are eligible to purchase coverage on a health insurance exchange but either can’t afford it, don’t think the insurance available offers a good value or don’t know they are legally required to obtain it. An estimated to the IRS for failing to get covered in 2014; millions more were from the requirement and didn’t have coverage.

In recognition of the fact that enrollment has been smaller than expected, the Congressional Budget Office recently for those who will buy insurance under the law from 21 million to 13 million in 2016.

CLAIM: The ACA has fixed the dysfunctional individual insurance market.

Prior to the passage of the health law, millions of people who did not have work-based or government coverage were shut out of buying their own insurance because they had been sick or because the coverage offered did not cover the services they needed.

The law aimed to address the problems in the individual market in , including requiring insurers to sell to those with preexisting conditions at the same price as healthier people; standardizing the benefits package; and limiting the size of deductibles. Tax credits were made available in order to help people afford coverage. And the law created intended to help consumers compare, choose, sign up and pay for health insurance.

How well these changes succeeded in stabilizing the market is not yet clear. What is clear is that are now insured through the market.

COUNTER-CLAIM: The ACA has made the individual market worse.

All is not well in the reformed individual market.

Even with help paying premiums, many moderate-income Americans are finding that their deductibles and copayments are so high they .

In other cases, individuals can get insurance they can afford to use, but it . In fact, plans that do offer coverage outside of the insurer’s network are becoming .

That change affected Cruz, who . In fact, and automatically transferred him to a narrow-network product.

CLAIM: The ACA has improved the Medicare program.

While most of the law was aimed at those without insurance, lawmakers also took the opportunity to beef up some benefits for the 55 million Americans in the Medicare program.

Medicare enrollees got for preventive services and annual checkups, and those with high prescription drug expenses got help to fill the “ gap left by the 2003 Medicare drug program.

Over the longer term, the law created several payment experiments intended to . These include efforts to prevent patients from going back to the hospital after they’ve been discharged.

COUNTER-CLAIM: The ACA has not saved money for Medicare.

The rate of increase in Medicare spending since the health law was passed in 2010. But it’s not clear how much of that can be attributed to the law, aside from some provisions that actually cut payments to hospitals and other health providers.

And some of the most highly anticipated projects, including “” that are paid bonuses for keeping Medicare patients healthy and lowering spending, have not so far shown very good results.

CLAIM: The ACA has killed jobs.

One of Republicans’ favorite talking points — that the health law would depress employment, particularly full-time employment — has turned out not to be the case.

An by the Urban Institute found that the health law “had virtually no adverse effect on labor force participation; employment; the probability of part-time work; and hours worked per week by nonelderly adults.”

While there would be fewer people in the workforce due to the law, the that “almost entirely” stems from voluntary actions by workers who could quit because they no longer depended on their jobs for insurance — now they could buy it on their own.

CLAIM: The ACA has slowed overall health spending.

The the fact that health spending grew at its slowest rates ever between 2010 and 2013. But health policy analysts are still about how much of the slowdown was attributable to the recession, to the health law and to other changes in the health care system.

Meanwhile, the rate of spending has begun to again, jumping from a 2.9 percent increase in 2013 to 5.3 percent in 2014. That has occurred as millions more Americans gained access to health care through the law.

This story was updated to correct a reference to the arguments about the health law’s effect on employment. Republicans suggest that the law will cut the number of full-time employees, not part-time workers.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

In August, Medicare officials  showing that the so far the ACOs have not . The 20 ACOs in the Pioneer program and the 333 in the shared savings program reported total savings of $411 million. But after paying bonuses, the ACOs recorded a net loss of $2.6 million to the Medicare trust fund, a fraction of the half a trillion dollars Medicare spends on the elderly and disabled each year.

To help put this development in perspective, Kaiser Health News posed this question to several ACO experts: Three years in, the ACO program has many success stories, but it’s not yet saving Medicare money. Is it working?

Here are their answers, edited for clarity and space.

Richard Barasch