IN LATE NOVEMBER, Sen. Chuck Schumer, a New York Democrat, publicly opined that Democrats blew it in 2009 by pursuing passage of the Affordable Care Act (ACA) instead of maintaining a focus on the economy.  Shortly thereafter, now-retired Sen. Tom Harkin, an Iowa Democrat and key ACA architect, opined that Democrats missed the chance to go all the way and achieve single payer health reform instead of the ACA’s less revolutionary approach.  Now in January, newly empowered Republicans are preparing to take down the ACA, either wholesale or brick by brick.

What’s a good law have to do to earn some respect?  How about showing meaningful results?  Among many things, 2014 was the year that the ACA began showing real traction with tangible results.  As the political warfare over the law continues, it’s worth recognizing these results.  I organize them into: 1. Access and insurance; 2. Quality; 3. Costs; and 4. Public Opinion.

Insurance Coverage: Improving access to insurance is the ACA’s key purpose.

Multiple surveys have converged on the figure of 10.6 million formerly uninsured Americans who got health insurance in 2014 because of the ACA.  The above chart shows the drop in uninsured adults under age 65, from 18.0 percent in mid-2013 to 12.9 percent in the fall of 2014.  Since the establishment of Medicare and Medicaid in the mid-late 1960s, we have never seen such a dramatic drop.  Let’s break the numbers down:

The chart above shows who is benefiting the most: folks with lower or lower-middle incomes (who are most likely to be uninsured), younger folks (ditto), and African Americans and Hispanics (ditto, ditto).  Though non-whites make up 28 percent of the US population, they represent more than 50 percent of America’s uninsured – so an expansion that disproportionately benefits them is doing its job.  So in addition to reducing the number of uninsured, the ACA is reducing racial and ethnic health inequities.  For another view on this, see this chart below:

The image below is one of my favorites, before-and-after ACA implementation in Kentucky, the state that saw the second highest jump in insurance coverage last year (Arkansas was number one).  Dark red is the worst and dark blue is the best:

In short, the ACA’s prime goal of expanding health insurance is happening.  Yes problems persist: For too many, cost sharing in the form of deductibles, copayments, and coinsurance, is too high.  For others, the subsidies still do not make insurance affordable.  Those are problems to fix.  And too bad that Congress is fixated on killing rather than fixing the law.

Quality of Care: Now let’s consider quality of care changes connected to the ACA.  Though the results are not as robust as coverage, good things are happening.

35,000 Fewer Medicare Hospital Deaths due to Health Care Acquired Conditions:

The above chart shows 35,000 fewer deaths of Medicare patients between 2011 and 2013 in US hospitals due to health care acquired conditions.  Patient deaths and injuries due to medical care mistakes first got major attention back in 1999 with the publication of To Err Is Human by the Institute of Medicine.  Ten years later, in 2009, experts concluded that the problems had only gotten worse.  The ACA includes tough new penalties on US hospitals with high rates of health care acquired conditions. Positive results are now showing, with the steepest drops in deaths from pressure ulcers, adverse drug events, and catheter-associated urinary tract infections.  Is this only because of the ACA? No.  Has the ACA compelled all hospitals to pay serious attention?  Yes.

Another area where the ACA has improved quality relates to the readmission of Medicare patients to an acute care hospital within 30 days following discharge.  While not all readmissions are preventable, many are.  Medicare experts believe that slowing readmissions is “low hanging fruit” to improve quality.  The ACA includes tough and growing penalties on hospitals with high readmission rates, and you can see the results below – 150,000 fewer repeat hospitals stays for Medicare clients.

Are there problems with this?  Yes – especially because the penalties do not differentiate hospitals with high numbers of poor and disadvantaged patients. Can these problems be fixed?  Yes, though only if Congress begins focusing on fixing and improving the ACA rather than killing it.

Here’s another. Most health policy analysts, regardless of political stripe, agree that the US health care system’s financing, based on fee-for-service that rewards medical providers for volume rather quality, is a key problem.  An ACA quality innovation encourages hospitals and physicians to form “Accountable Care Organizations” (ACOs) to improve care with better coordination and efficiency, and to share in resulting savings.  When the ACA was signed in 2010, cynics noted that ACOs were like unicorns, interesting in theory and nowhere to be found in real life.  No more:

Currently, more than 400 ACOs are working in the Medicare system, with ACOs now appearing in the private market as well.  It’s true we don’t know how well this experiment will work, but according to the US Centers for Medicare and Medicaid Services (CMS), ACOs now serve 7.8 million Medicare enrollees, improved quality on 30 of 33 quality indicators in two years, and generated $417 million in savings.  And ACOs are just one of many ACA quality innovations.  Why pull the plug?

ACA and costs.  Of course, costs cut in many directions – to the federal government, the overall health system, consumers, providers, and more.  Let’s look at key indicators, starting with the ACA’s overall cost:

This chart, from the Congressional Budget Office (CBO), shows the predicted and actual costs of the ACA. The top line shows the CBO’s estimate of the ACA’s total costs when the law was signed in 2010. Three years later, in 2013, the estimates had dropped, and by 2014, much further. Meanwhile, projected costs of Medicare and Medicaid have declined dramatically since 2010, especially Medicare – so much so that today’s expected cost of Medicare, Medicaid, and the ACA is less than the expected total cost in 2010 of Medicare and Medicaid alone (see below).

The Kaiser Family Foundation estimates that the difference between real Medicare spending in 2014 versus the 2010 projections were $1,209 lower per beneficiary, and are projected to be $2,436 lower by 2019, an astonishing deceleration that has occurred without cutting eligibility or benefits.  Overall, over the past five years, we’ve seen the slowest sustained rate of health care cost growth since the nation began keeping track more than 50 years ago:

Still, health care is way too expensive for many Americans, and the rising tide of cost sharing in the form of deductibles and other charges is causing real pain.  This could be addressed and improved if Congress were willing to use unanticipated ACA savings to improve affordability.

Some say all the lowered cost growth is tied to the 2008 recession that ended in March 2009.  But the recession cannot explain the Medicare spending slowdown because Medicare spending is not impacted by economic downturns.  The slowest rate of health care spending growth in modern history – that’s another unrecognized accomplishment of the ACA.

Public Opinion: Finally, let’s consider public opinion.  The ACA’s unpopularity is well known, as the Kaiser Family Foundation has been tracking since 2010:

What’s less known – and is shown below – is that many ACA elements are popular:

The exchanges, the insurance subsidies/tax credits, the Medicaid expansion, and even the employer responsibility provision all enjoy support.  Many Americans who support these provisions do not realize they are included in the ACA; many believe that the law contains bad provisions that are not actually included.  For example, consider this anecdote from a recent New York Times article on the ACA in Kentucky:

“I don’t love Obamacare,” [Ms. Mayhew] said. “There are things in it that scare me and that I don’t agree with.” For example, she said, she heard from news programs that the Affordable Care Act prohibited lifesaving care for elderly people with cancer.

There is no such provision, although a proposal to pay doctors to engage patients in end-of-life planning — such as whether they would want life-sustaining treatment if they were terminally ill — was removed from the law after it sparked a political firestorm over “death panels.” The misperception remains widespread: A poll this month by the Kaiser Family Foundation found that 41 percent of Americans still believe the law created “a government panel to make decisions about end-of-life care for people on Medicare.” An equal number found the law did not.

“If we have Obamacare and the insurance is available to me, I will use it and be thankful for it,” Ms. Mayhew said. “But would I gladly give up my insurance today if it meant that some of the things that are in the law were not in place? Yes, I would.”

Researchers at Stanford University wondered whether people’s favorability toward the ACA was correlated with how well they actually understood the law.  They asked people questions to test their knowledge of the ACA and then matched that with their favorability toward the law, and here is what they found:

The more people understood the law, the more they liked it, whether Democrat, independent, or Republican.

All of which leads me back to Sen. Schumer stating that Democrats would have been in better off had they put health reform 3, 4, or 5 on their list instead of number 2, right after the federal stimulus law.

I believe that Democrats would be in a far better if they had focused on explaining and selling the realities of the law to the American public over the past four years.  If they had put health care at number 3, 4, or 5 instead of number 2 (after economic stimulus), it never would have happened.

One final thought. Consider the striking and sustained deceleration in health care spending over the past five years.  Though I am not an economist, I wonder what impact lowered health care spending has had on improving the nation’s economic recovery?  One prime reason the nation began the health reform odyssey in 2009 was the widely-held belief that we could never restore the economy until we got health care costs under control.  They are under control (for now) and the economy is markedly improving.  Not cause and effect for sure – but unrelated?  I think not.

The ACA is working.  Pass it on.

John E. McDonough is a professor at the Harvard School of Public Health and the author of Inside National Health Reform.