Intended for healthcare professionals

Clinical Review State of the Art Review

Obamacare: what the Affordable Care Act means for patients and physicians

BMJ 2014; 349 doi: (Published 22 October 2014) Cite this as: BMJ 2014;349:g5376
  1. Mark A Hall, professor of law and public health,
  2. Richard Lord, professor and chair of family medicine
  1. 1Center for Bioethics Health and Society, Wake Forest University, Winston Salem, NC 27157-1063, USA
  1. Correspondence to: M A Hall mhall{at}


The Affordable Care Act’s core achievement is to make all Americans insurable, by requiring insurers to accept all applicants at rates based on population averages regardless of health status. The act also increases coverage by allowing states to expand Medicaid (the social healthcare program for families and people with low income and resources) to cover everyone near the poverty line, and by subsidizing private insurance for people who are not poor but who do not have workplace coverage. The act allows most people to keep the same kind of insurance that they currently have, and it does not change how private insurance pays physicians and hospitals. Although the act falls short of achieving truly universal coverage, nine million uninsured people have received coverage so far. Market reforms have not hurt the insurance industry’s profitability, prices for individual insurance have been lower than expected, and government costs so far have been less than initially projected. The act expands several ongoing pilot programs in Medicare that reform how doctors and hospitals are paid, but it does not directly change how private insurers pay healthcare providers. Nevertheless, it has set into motion market dynamics that are affecting medical practice, such as limiting insurance networks to fewer providers and requiring patients to pay for more treatment costs out of pocket. In response, many hospitals and physicians are forming closer and larger affiliations. Further time and study are needed to learn whether these evolutionary changes will achieve their goals without harming the doctor-patient relationship.


  • We are grateful to colleagues Curt Furberg and Greg Burke (Wake Forest University) for encouraging us to write this article and for insightful comments on an earlier draft. They do not necessarily share all of the views expressed here.

  • Contributors: MAH made substantial contributions to the conception and design of the work and the analysis and interpretation of data, and drafted and revised the article, with final approval of the published version. He is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. RL made substantial contributions to the portion of the article that deals with impacts on physicians. For this portion, he contributed to the conception and design of the work, the analysis and interpretation of data, and the drafting and revising of the article.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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