More than any subject since I started this column, I have written about the Affordable Care Act (ACA, Obamacare). It is not really surprising. Something as big as the ACA doesn’t come along often, and while not exactly, it is on the order of the introduction of Social Security and Medicare.

Shortly after it was signed into law on March 23, 2010, I spent time speaking to various groups explaining how it would work. I always tried to “stick to the facts” and not be outwardly in favor of or against it. As a representative of the Texas Tech University Health Sciences Center School of Medicine and Texas Tech Physicians, I never felt that I was there to condemn it or promote it. I would usually say something like, “It is a mixed bag as it has some very good features and some things needing to be worked out.” I felt that being agnostic on the ACA was my best approach.

Now that five years have passed, let’s see how those things have turned out.

First, many good things have come from it.

• ACA has benefited approximately 23 million people who have signed up for a new plan from an exchange or Medicaid.
• It is helping those who have a pre-existing medical condition such as heart disease, diabetes, asthma or cancer by eliminating underwriting for pre-existing conditions.
• Insurers are now required to cover a range of recommended preventive services, such as screenings for cancer, diabetes, high blood pressure and flu shots without additional cost-sharing such as co-pays or deductibles.
• ACA eliminated lifetime caps on insurance coverage.

What about the things that are not so good?  

• Well, the rollout of the online exchanges was a disaster. Although, they are working well now, making that problem ancient history.
• Americans will probably not care for the “Cadillac tax” on higher-cost health plans that starts in 2018.
• Tax penalties for not having insurance are going up each year, and that is likely not to be popular. It was the lowest it will ever be in 2014. It goes up steeply this year to $325 for each adult and $162.50 for each child, but no more than $975 total per family or 2 percent of the family's yearly taxable income. In 2016, it will be $695 for each adult and $347.50 for each child, but no more than $2,085 per family or 2.5 percent of the family yearly taxable income.
• Under the ACA, states have the option to expand Medicaid eligibility to individuals who earn about $16,000 a year, and the federal government will cover much of the additional cost. But 21 states, including Texas, have not done so because of political opposition to the law. Whether this is good or bad depends on one’s political and economic views, but the issue falls in the ACA’s “problem” column because it is not the way it was designed.
• There has been no action, yet, on addressing rising health care costs. Therefore, while more people have insurance coverage, many root problems remain in the system.
• Finally, according to polls, the concept of the law’s individual mandate remains unpopular.

After five years, it seems to me that it is time for leaders all across our great nation to address “those things that need to be worked out” and thereby improve the ACA. Since it seems to be here to stay, attention should be focused on maintaining its merits and correcting any problems with the ACA. If this approach is pursued, it could fine tune a program that clearly benefits a great number of Americans (and potentially millions more), while concurrently enhancing our health care delivery system.