The effect has not been even throughout the country, however. The Act included funding to assist states in expanding Medicaid to low-income populations who were previously ineligible. However, Republican governors in some states chose to refuse the funding.
Obama breaks down the improvement between states that did and those that did not expand Medicaid. As the graph below shows, the reduction in the uninsured proportion of the population is strongly correlated with the number of uninsured prior to the Act's introduction, but the fall has been considerably larger in the states that accepted the additional Medicaid money.
Moreover, Obama claims, “The law has also greatly improved health insurance coverage for people who already had it,” since certain minimum services must be included, such as "maternity care and treatment for mental health and substance abuse disorders, services that were sometimes not covered at all previously.” Prevention is usually cheaper than cure, and the Act has prioritized this in a number of ways, as well as banning the lifetime limits on payments that often saw families go bankrupt when a member was stuck with a particularly expensive condition.
Costs for the US healthcare system as a whole have risen at the same rate as inflation, compared to far more rapid growth in the previous decade, something that had been expected to continue prior to the Act.
As Obama argues: “Many of the reforms introduced in recent years are still some years from reaching their maximum effect.” However, he does not regard the project of reforming the US health system, which continues to cost more than any other country while delivering lower measurable standards than the rest of the developed world, as completed. Consequently, the paper includes ways the Act could be extended to improve it further, including a “public plan” that was in the original act, but was dropped in order to win support from wavering senators.
JAMA also ran four editorials from public health experts with varying perspectives on how successful the act has been.