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Barack Obama

President Barack Obama reaches for a pen to sign the health care bill on March 23, 2010, in the East Room of the White House in Washington. Now the administration is in a sprint to put it into place.

On March 23, 2010, President Barack Obama signed a law that would shake up the entire health care industry — and American politics.

The landmark Affordable Care Act, which marks its fifth anniversary on Monday, has survived bruising legal challenges, a disastrous rollout and countless political tests, including multiple votes in Congress to repeal it. And it has always been — and remains — unpopular among half of the population.

Challenges remain, including another court case that could unravel a key part of the law. But regardless of future problems, Obama’s signature domestic achievement has already left its footprint on the health care sector.

Designed to expand access to affordable health insurance, curb the cost of care and make Americans healthier, the law has probably irreversibly changed how consumers interact with the industry.

Health care spending still comprises about one-fifth of the entire U.S. economy. That’s almost twice the spending of many other developed countries whose citizens have a higher life expectancy. The Affordable Care Act sought to change those statistics.

On the coverage front, more than 16 million Americans have gained insurance because of the law — resulting in a 35 percent drop in the uninsured rate. But whether that insurance is affordable is still a point of controversy.

For Isabel Ackerman the law significantly reduced her health care spending. Ackerman, 56, was previously able to get insurance only through a high-risk pool that required her to spend more than $600 a month in premiums alone.

That’s because she was turned down for private insurance. She had pre-existing conditions on her medical record, including fatty liver disease and high blood pressure. But the Affordable Care Act barred insurers from denying coverage based on pre-existing conditions.

Now, Ackerman pays $500 a month — $1,200 per year cheaper than her old plan — for private coverage. “It’s much better,” she says.

Others haven’t been so lucky. Julius Krisanic owns Wholesale Siding Depot, a building material distributor, near Kirkwood. He says the health insurance cost for his small business of 12 employees has doubled since the law was signed.

“I can’t comprehend these increases and how they justify them,” he said. “To me, health care is just totally out of control.”

Krisanic pays the entire premium for his employees’ health coverage, though they still owe a deductible. He has not taken a paycheck in some cases to help pay his business’s health bill.

In many areas, including St. Louis, premiums for individuals rose this year but at a more modest rate than before the law took effect. But others, particularly small businesses, have faced higher costs as a result of new rating schemes imposed by the law.

The conflicting experiences have been a major challenge when it comes to public perception of the law. It’s left many thinking it created winners and losers.

The Kaiser Family Foundation has tracked opinions about the law since 2010. Its latest findings from this month show the law is as divisive as ever. Forty-three percent of poll respondents disapprove of the law, while 41 percent like it.

The partisan breakdown is even more telling. Of those who identify as Democrats, 65 percent approve the law. Nearly three-fourths of Republican respondents, however, continue to disapprove.

The continued resistance to the law means that many can’t take advantage of several key provisions. Republican-led states have resisted implementing Medicaid expansion under the law. In Missouri, that means about 180,000 people still can’t get insurance. Other states have similarly resisted, creating an uneven experience for many consumers.

The law’s success is even more ambiguous when it comes to reining in costs across the sector. Increasingly, patients and providers are being asked to take on more responsibility.

For patients, this comes through higher deductibles and other cost-sharing tools. Providers are also under pressure to cut costs and improve outcomes through payments based on value and a patient’s health.

Many of these ideas were around before the law was signed but took on an added importance as its provision went into effect. They include penalizing hospitals for high rates of readmissions and infections, while also providing bonuses for high patient satisfaction scores.

Through Medicare, the government is also experimenting with giving hospitals a set amount of money for a specific surgery, such as a knee replacement, instead of reimbursing providers for every individual aspect that goes into the procedure.

In theory, the changes should lower prices by making people healthier, thus resulting in fewer costly hospitalizations and other expensive care. But the practical implications are another matter. There’s concern they could lead to more hospital consolidations, which may end up being a detriment to patients.

“Studies have shown that these kind of activities tend to put prices and costs up and rarely improve quality,” Austin Frakt, an economist, said about hospital consolidation. “It’s pretty clear that prices go up and quality does not improve.”

But other experts say the new payment models being implemented under the Affordable Care Act are part of the reason health inflation has subsided.

“This might be one of the reasons why we are seeing pretty historical slow growth in health care spending,” said Tim McBride, a health economist at Washington University.

The government also insists that they are keeping Americans healthier.

This report was prepared in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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