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Obamacare 10-Year Status Report

medicaid, medicare, equitable coverage, continuously improving care

October 3, 2023

Affordable Care Act

The Affordable Care Act has had significant and important successes, at multiple layers and levels, that people who look at health care issues usually don’t see, understand, discuss, or appreciate. The Affordable Care Act doesn’t get the respect it deserves because far too many people don’t know that those important, significant, and very real successes have happened.

Medicaid has covered nearly a 100 million low-income people who very much needed that coverage. The law has also now given more than half of the people enrolled in our Medicare program much better benefits and measurably better care.

The law has also ended some inappropriate levels of discrimination and excessive profits from the health insurance industry, and it’s created access to coverage for people with pre-existing conditions that didn’t exist before the law was passed.

It also started tracking care quality in key areas relative to heart attacks and hospital-related infections that we needed — and that we absolutely didn’t have as a nation before we passed that law.

The law has put us on a path to continuously improving care in large numbers of our care sites through Medicare and Medicaid, and through our Accountable Care Organization sites, in ways that people don’t understand or appreciate, but that will create permanent differences for the better for patients in those settings.

Advocates for the Affordable Care Act often said during the enactment process that it was a complicated and extensive law, and that they believed that when people understood what actually happened and could see what all of the component parts actually were, they would be very supportive of the law.

We’ve now had a decade to see if that’s true.

The law has been functionally in effect for slightly over a decade now so this is actually a very good time to reflect on what the law intended to do and what it actually accomplished during those years.

It clearly worked for our lowest income people.

We’ve done many things for our lowest income people that haven’t been part of the public awareness level. We now have care programs in the lowest income Medicaid-related settings that we know are doing the right things for people getting that care, and those care levels and that care quality would not be there without the law.

We've also just reached the point where more than half of the enrollees in Medicare are now in Medicare Advantage plans with much better benefits and lower costs. The Medicare trust fund just went from decades of losses to making a surplus and a profit of $83.4 billion for 2022.

That's a major turnaround for Medicare.

It's game changing for Medicare to make more than $80 billion in a single year.

We know that the Medicare trust fund has gone from decades of deterioration in the trust fund financial status to the point where the trust fund is now growing and will continue to grow with absolutely no chance of losing ground on that trajectory, because the payment model run by CMS and the current administration for Medicare Advantage can guarantee that cost advantage will continue because they directly and explicitly and intentionally control what those costs will be.

Medicare Advantage

When Medicare’s total revenue as a program grows by roughly 7 percent each year, then any expense levels that grow beyond that create losses for the program. And any expense levels for the programs that fall below that 7 percent directly increase, enrich, reinforce, and enhance that fund. The absolute reality is that Medicare Advantage is now over half of the enrollment and the cost increase level for those members is growing in 2023 at roughly 4 percent, because CMS has determined that number for that year.

Slightly more than a decade into the program, that is an extremely important set of numbers. It’s extremely beneficial and important for the ongoing solvency of our Medicare program to have Medicare Advantage creating those lower costs and lower expense numbers for their members.

When the law was passed, the people who designed the bill said that they expected and intended that result would happen over time because the Medicare Advantage program was designed and intended to achieve those goals. People in the media and in many academic settings didn’t understand what that cost and expense goal or strategy for Medicare Advantage was, but the people who wrote and passed the bill understood it completely and are now vindicated in this result, because it succeeded.

When the bill passed, most of the public discussion and debate was about the private insurance provisions of the program. The fact that people with pre-existing conditions far too often couldn’t find insurance coverage dominated the debate and public discussion. That set of insurance issues was an important and visible topic, but it was far from the highest impact portion of the legislation and it’s also far from the highest positive impact from the Affordable Care Act we see after a decade of having the law in place.

The bill had four major component parts that were all very much needed by the country, because we had significant problems and challenges on multiple levels in both our coverage and care. The people who wrote the legislation looked at the entire set of issues in writing their component parts and, for the most part, a decade later we can see that we’ve made significant progress on every portion and each key agenda.

The American health care system had multiple badly performing and unaffordable elements, and the insurance laws for the nation weren’t set up to protect and enable peoples’ ability to get insurance when it was most needed. People with pre-existing conditions could be, and often were, turned down for coverage and care when they needed it.

Before Obamacare passed, there were no limits on the possible profits for health insurance companies.

We had huge coverage gaps.

The majority of our lowest income people actually didn’t have coverage in almost every state.

Our standard Medicare program for our seniors was our most popular government program, but it had no quality requirements and very weak benefits, and it cost a lot of money for both our government and our patients. Far too many of our oldest people were damaged financially and even bankrupted by the costs of care that existed with that fee-for-service Medicare program.

We were the only Western country that didn’t provide coverage to our lowest income people. That was a major deficiency in our system that needed to be corrected as soon as possible. The goal for our lowest income people was to cover everyone and do it with better care.

People who look at Obamacare in public and policy settings generally focus on the more visible insurance related issues and on the exchanges, but that was actually a smaller piece of the law, and it was less significant and less impactful than all of the work that’s been done in the last decade for both our poorest and our oldest people.


We addressed the extremely important and painful issue of our lowest income people not having coverage very directly by expanding our Medicaid program extensively.

We did extremely important, easy to accomplish, and almost invisible things with our Medicaid program. We made Medicaid eligibility an income factor and we supported Medicaid expansion in every state.

Before the Affordable Care Act, the quality of care in Medicaid settings was far too often flawed and not linked to best practices or better care. We’ve now improved that situation significantly for more than 90 million people in very intentional ways that we should be celebrating as a country.

We now have 86 million people enrolled in Medicaid and we have another 7 million people enrolled in the CHIP program for children.

All those programs are now explicitly and directly linked to care quality and service availability monitoring. We have created, triggered, structured, and funded a new culture of patient-focused care for those populations that’s changed that part of the country and changed our support systems for the better in significant and important ways for those patients.

You can visit any of the big and visible annual and public meetings for the people who run the Medicaid plans or who run the Medicaid programs for the states, and you can easily see a vast and growing wealth of care expertise and patient-focused approaches in growing numbers of programs and settings.

The people who run those plans and programs are competing on multiple levels in often collaborative and mutually supportive ways to offer continuously improving care to their members, patients, and enrollees.

That is a huge and important difference from the often inept, bureaucratic, rigid, inflexible, functionally limited, and too often inadequate and less effective sets of care delivery practices that were in place across the country for far too many Medicaid patients before the Affordable Care Act moved a steady flow of money into those settings — and then created that entirely new set of expectations, values, and even resource priorities for those patients and programs that were funded with that money.

Our biggest health care deficiencies and most damaging care inadequacies as a nation before that law was passed included our inadequate programs and our flawed approaches for our lowest income patients served by those old Medicaid programs.

Obamacare has been transformational on multiple levels for those people and Obamacare is on a path now to make that care even better, using the new and evolving tool kits for care extensively and well.

Most of our health care academics and policy people have no sense of any of that activity, performance, or achievement for those patients.

Far too many of our health care journalists and media sites do nothing to look at or understand and appreciate the extensive levels and layers of care that’s now delivered in so many settings to those millions of low-income patients and to people who so clearly need that care.

That’s important work.

We should celebrate it.

If Medicaid expansion was the only program that had been created by the Affordable Care Act a decade ago, people would be justified in calling the entire law a success. That’s a major, significant, and absolute win for millions of people who need and deserve that support and care.

It’s been a very good decade for those programs and for those patients. We should appreciate and celebrate those enhancements and achievements as a nation as we look back on the decade now. We should also think about what we’ll be able to accomplish now with the new tool kits for care for those people and with the growing awareness and focus on various social determinants of health problems and deficiencies that affect those patients so directly, and that lend themselves to continuous improvement on several levels for those issues.


The second intentional and deliberate major goal of the Affordable Care Act was to have the Medicare program for the country change from being a fee-for-service payment system that rewards and financially encourages poor care outcomes and failing care process — into being a program and a payment model that encourages and rewards care improvement on a level that also reduces the cost of care for our older patients.

That Medicare Advantage component of the Affordable Care Act has also been an overwhelming success. It‘s achieving the goals that the drafters of the law intended it to achieve. It has some hardcore political opponents who completely and totally miss the point of what just happened.

When you look at actual performance and the actual costs of the program, the information for 2023 shows that Medicare Advantage just saved the Medicare trust fund by costing less and by providing better benefits and better care to those members that will make the members loyal and supportive of the plans.

The program has grown in popularity each year. And with the 2023 enrollment results, we’ve reached the historic and functionally significant point where over half of all Medicare Members are now in Medicare Advantage plans.

The positive impact of that approach is obvious and extremely important.

The Medicare trust fund just reversed a 20-year trend toward insolvency with growth in the trust fund last year. It’s now on a path to permanent financial adequacy because it will continue to grow every year with the majority of members now in Medicare Advantage plans — and with CMS intentionally and significantly using its power, authority, and ability to set payment levels for the capitation process that guarantee success in those areas on an ongoing basis for Medicare.

Medicare Advantage spends less and makes much better use of the Medicare dollar.

Benefits are far better than traditional Medicare.

The plans are paid a capitation to provide the basic benefits, and the plans can then use that capitation money to both improve care and to enhance benefits for the members in ways that the plans intend and believe will increase member satisfaction and create both functional enrollment loyalty and enrollment growth over time.

The average cost of fee-for-service Medicare in each county creates the capitation level and the basic benchmark data for the plans. That’s extremely important and very relevant information, and it happens every month.

It’s easy to explain how and why that combination of financial outcomes happens for the plans and why the plans can offer better benefits while spending less.

The care differences are huge.

Fee-for-service Medicare has much higher rates of blindness, significantly more congestive heart failure crises, many more asthma crises, and far more amputations for their members than the capitated plans and patients in Medicare Advantage.

That higher and more expensive level of care that happens every month in the fee-for-service Medicare settings creates a high average cost for those settings and the plans get to bid against that high cost as a cash flow benchmark when the plans bid set their capitation levels for each county each year.

The very first Medicare Advantage five-star plan quality measure is based on the basic practical and functional medical reality that you can cut the blindness rates by more than 60 percent for patients by managing the blood sugar levels of diabetics. That quality measure and that target in the five-star quality plan is to manage and reduce that blood sugar level for those patients.

That’s an area where the blood sugar measurement control success that happens in fee-for-service Medicare for low-income patients is now under 40 percent. Far too many patients are losing their vision with that unfortunate situation and care level.

The current and visible and public data shows that over 90 percent of Medicare Advantage plans now achieve their five-star program goals., Because that is true, the plans all have fewer people going blind and fewer diabetic patients incurring those expenses, as well as the other expenses that result from those unfortunate levels of care for the fee-for-service patients.

Some Medicare Advantage critics attack the program and the plans, but then those critics carefully avoid the obvious better care in those settings in their attacks. They actually say in published settings like Health Affairs that the Medicare Advantage successes are based on risk coding complexity successes rather than care delivery successes or processes.

What is true is that the plans save significant amounts of money by delivering much better care and the plans use those savings from better care to create better benefits for their members at lower costs.

The Medicare Advantage Plans generate significant surpluses every month from the difference between their bids and their actual costs. Those surpluses are very visible, and they each represent real cost savings for Medicare.

The surpluses create dental, vision, and hearing benefits along with other support services for their members. The surpluses are all created from discounted bids that currently average 15 percent lower than the average costs of fee-for-service Medicare in those counties, so every surplus is free money for Medicare.

Free money is a much better use of the Medicare dollar.

Some plans take their surpluses and even buy the Medicare Part D coverage for their members. The Medicare Part D program receives some of its money each year from some of the Medicare Advantage plans.

The academic community, the policy community, and the health care media and reporting teams have very consistently managed to not understand or tell or report the story and fact that the Medicare Advantage plans deliver care that is so much cheaper than the average cost of fee-for-service Medicare that the Medicare Advantage plans can give free drug coverage to those members in those plans and still make far better use of the Medicare dollar.

The enrollment information and the enrollment distribution that we see now for the plans is particularly useful, relevant, and important in evaluating how well that program is doing for a 10-year Affordable Care Act report card update.


Poor people in large numbers join plans.

More than two out of three low-income Medicare Members are in plans. More than 70 percent of African American members and almost 80 percent of Hispanic Medicare members are now in plans.

There’s probably no other health care program in the country that does as many good things for our Hispanic patients as Medicare Advantage, because there are language and service requirements for the plans that don’t exist in fee-for-service Medicare. Many of the Hispanic patients who’ve been badly damaged over their lifetimes on several levels by various social determinants of health inequities and equity issues are now getting team care and patient-focused care for the very first time in their lives, as members of Medicare Advantage Special Needs Plans.

We don’t have any other program in health care that does as much for the lowest income people with dual eligibility for both Medicare and Medicaid as Medicare Advantage.

We now have more than 5 million of those high-need and low-income people enrolled in Medicare Advantage Special Needs Plans where they get much better care, much more successful care, and care that we need to protect from the critics and the plan opponents who want those programs to lose funding and to lose support, and to be forced to have lower levels of those benefits that those patients need badly.

The people who make up false and misleading information about the coding levels of our patients also want to reduce those benefits for those high-need and low-income people. That would be absolutely wrong because those patients in the special-needs plans have been damaged for so long by social determinants of health problems in so many ways, and those low-income patients don’t need additional damage now by not providing those expanded benefits that directly support their lives.


Most people who look at the law also don’t know about the support for retired members of the work force that it creates for the country using Medicare Advantage.

We’re also providing an extremely important service and benefit for retired people who were employed and who had health coverage on the job while they worked and who expected to have their employer- and union-based health benefits and health coverage continue and exist permanently for them after their retirement.

When the Affordable Care Act was passed, the people looking at the situation who were writing the law more than a decade ago knew that many of our workplace-based retirees expected to have lifetime coverage continue from their employer and from their union trust fund and counted on that coverage for their retirement years. The people who wrote the law knew that not all of those future expectations were clearly and adequately funded by those employers. The people who wrote the law knew that painful economic reality for those work settings had the potential to create some real long-term problems on health care coverage for millions of retirees.

Rather than have a number of those retirees who had worked hard their entire lives actually be without needed coverage in their years of their retirement, Obamacare and the Affordable Care Act built in a special and targeted program for retirees and trust funds that allowed the plans and unions to continue that coverage forever in their retirement years as Medicare Advantage enrollees and programs.

That worker retirement program immediately enrolled more than 5 million people in the first years of the program. Those retired workers are a steady and anchor part of the Medicare Advantage enrollment.

The health care economists and health care policy makers and almost all of the political pundits who are writing about the impact of the Affordable Care Act completely missed seeing or understanding that program and approach, even though it’s extremely important on a personal level to that set of people and for those retirement funds and benefits. It would probably be politically difficult for future congressional or administrative approaches that could put those retirement plans for millions of workers at risk to get any congressional support or political leverage.

The Medicare Advantage critics who don’t mention or write about the special-needs plans and their benefits are also usually careful not to describe that program or what it does with extremely high satisfaction levels and high quality scores for those retirees. So, most policy people and most economists don’t know that program and support system exists, and it doesn’t get the credit it deserves when people look at Obamacare and its overall results.

But if we’re doing a 10-year status report now on the Affordable Care Act, we can see that Obamacare has been a major success for Medicaid and for Medicare on multiple levels. It’s on a good trajectory to have those successes continue.

We can see that the Affordable Care Act was a major success for the people who’ve retired and whose future health benefits are now safely in place because they’re embedded in Medicare Advantage plans and can count on those benefits continuing.


The private insurance market part of the overall Affordable Care Act approach and program was the most visible and highly political part of the program when the law was passed. The private insurance components of the law had their own successes that should be recognized, understood, and included in our future planning for health care financing and delivery in America — and in our current 10-year assessment of how well the law is performing today.

We forced insurance Companies to improve their performance in several key areas and we put real and important caps on the profits that insurers could make in those markets, and those were both major successes for the law.

We outlawed insurance companies from being able to reject people from coverage for having pre-existing conditions, and we did that by creating an entire insurance marketplace that relies on private health plans for coverage.

One of the best, most appropriate, and most effective provisions of the law eliminated the ability of insurance companies to make unlimited profits if they could find products and customers that allowed that level of profits to happen.

The loss ratio regulations in place now for the insurance industry allow the companies to keep up to 15 percent of their insurance premium for both administrative costs and profits. For example and context, there have been times, settings, and situations in recent history where some insurance company profits exceeded 50 percent of their premium, and that’s no longer possible with the new law.

Some of the people, who continue to oppose having insurance companies in the process or mix at any level, repeat the stories of the insurance plans that made those huge profits from their premiums in some settings and situations in the past, and the insurance company opponents who report that history sometimes make it sound as though those levels of profits are somehow possible or a risk for insurance companies today.

That’s not true.

The Affordable Care Act made those profits illegal, and they’re no longer part of the business model for any health insurance company in our country today.

The law did carefully set up insurance purchasing mechanisms in every state to function as insurance exchanges using any insurers who wanted to compete for their customers who came to them from that market context and setting.

We now have about 20 million people who are enrolled in those state-run exchanges in our various states. Most of the current enrollees who are in the exchanges have some subsidies for their premium payment based on programs available to them in their states and settings when they enrolled.

When we look at the total insurance marketplace for our country, if we remember that a basic principle, key functional premise, and working goal of insurance is to have an adequate and legitimate risk pool and cash flow for coverage for each set of insured people, then we can think of those subsidies as being the mechanism we use to include those enrollees as part of the overall risk pool. We shouldn’t think of the subsidies as an isolated set of cash flows that have those enrollees existing as a separate insurance reality and as a separate business case for financing care.

We need to have a macro cash flow for care that includes everyone in the overall risk pools we create for the nation — and we achieve that goal in an inclusive and legitimate way by subsidizing enrollment for some of those members in the exchanges.

The vast majority of the people who are enrolled in the overall nongovernment markets for our country in every state still actually have employer-linked coverage. Most insured people in their country have their coverage purchased in employer settings with employer support for the payments in almost every setting.

One of our goals in setting up the Affordable Care Act in its current form was to maintain, continue, preserve, and keep that set of cash flows from all of those employers coming for health care for their employees.

That’s exactly what most European countries do now to create universal coverage for their members. They link coverage to employment and link coverage to employers.

Most Americans do not understand that system or know or even see what they actually do in all of those countries to link coverage to employment.


Most Americans who’ve seen the Canadian single-payer system for coverage assume that every country in Europe uses that same Canadian style single-payer system to cover their people.

That is absolutely not true.

There are absolutely no single-payer systems in non-Scandinavian continental Europe. The Scandinavians have chosen to employ their caregivers as government employees — with no fees anywhere in those care sites — and every other country uses actual functioning health insurance plans to provide coverage and care.

The governments in each country tend to link health coverage directly and explicitly to employment. Those countries have the employers pay at least half of the premium for their employees, and the employers usually select the insurance plans that will be offered to their employees.

Those countries all want to encourage and support employment as a public policy and economic system, and making health benefits part of the employment situation for each worker helps make that happen.

A strong and almost overwhelming majority of health care academics and health care policy makers, and even health care journalists in our country, basically have no idea how the European system actually works.

Chancellor Bismarck of Germany decided over 100 years ago to unify Germany by making health care universal as a condition of employment.

It worked so well that others have followed his lead.

Bismarck invented competing health plans — very much like the ones we use to run our Medicare Advantage program here. He created a market model for care delivery and coverage because he didn’t want the government running and delivering care.

They created a 15 percent payroll tax for each paycheck, and they split it between the employer and the employee for cost.

They did not decouple and separate employment from health insurance, as the vast majority of American health care policy people, politicians, and academics often claim in discussions about that process and those countries today.

The employers in those countries play a major role in the process. And the employers in those countries choose which health plans they offer to their employees.

The plans compete based on service, benefit design, and care components. Hundreds of plans have managed to survive for more than 100 years in Germany by doing those functions well, and by keeping their customers happy.

Switzerland uses the same exact model.

Not one person in Switzerland has government Canadian style single payer coverage.

They all link to the plans chosen by their employer. When they change jobs in some Swiss Cantons, the local police in those areas of Switzerland require each person to tell and register with local authorities where they will get their care with their new job.

They use a process in Switzerland that echoes what we do here with Medicare Advantage eligibility when enrolled people change their living situation and need to choose a new plan — because the plans are all geographically linked, and the old plan potentially doesn’t work for continued access to coverage for the patient who has moved to a new dwelling.


The biggest difference between the European model and the American model relative to health care issues, one that’s been a major deficiency and a significant failure for us as a country, is the cost of pharmaceutical care.

We pay $300 per dose on some drugs that they buy in France or Spain for $30 per dose.

The big cost hole in the Affordable Care Act has been prescription drug costs.

That happened because drug costs would’ve been “a bridge too far” to get the Affordable Care Act bill passed, and the bill wouldn’t have passed if we had tried to deal with that issue at that point in time. They only created about 15 percent of the total cost of care — so creating Medicaid for all of our poor people, and Medicare Advantage for our seniors, and creating the insurance exchanges for the people with pre-existing conditions was enough to achieve at that moment in time. So, drug prices and their control were left completely and deliberately out of the Affordable Care Act package.

The good news on that particular issue — as we look at this 10th anniversary update for that Affordable Care Act law and approach — is that we’re finally beginning to close that particular hole in that health care cost bucket for our country with new legislation on that issue being passed and implemented now.

We know how to close that hole.

We’ve been the only Western country that hasn’t set and regulated drug prices at the government level.

We just passed legislation that deals with that issue and the good news for our long-term cost situation is that the hole in our process is now being closed with the very first set of drugs going into government price arrangements here.

That approach of having our government now involved in negotiating the prices of drugs is directionally correct and should get us to a good long-term result because it’s worked in every other country that has done it. We just need to hold the course and get good at doing it here.


So, the Affordable Care Act has made government programs and coverage much better. It’s made access to coverage significantly better, and the people who said that you need to understand the law more completely to appreciate it more completely were on track for that agenda and they might find this first decade update useful for both scope and context for the process.

Care should now be getting better in significant ways.

We now have much better and continuously improving care design elements as a result of those new purchasing models for government coverage. Medicaid and Medicare Advantage plans are using the new tools in increasingly good ways and they’re sharing that skill set and those tools with each other in very public ways.

We have Accountable Care Organizations and other care improvement approaches being built into our payment processes at several levels now. Many good things are being done for patients in those settings that we need to support, continue, and enhance as a country.

The costs of Accountable Care Organizations aren’t much lower than the average costs of fee-for-service Medicare, but the care is far better on multiple levels for those patients, and we should celebrate that success. We should encourage everyone who isn’t enrolled in either a Medicare Advantage Plan or a Medicaid plan to seek care through an ACO, and we should continue to use those approaches to improve outcomes and care.

We made major and long overdue improvements in our care delivery when the Affordable Care Act began requiring hospitals and care sites to record infection data, hospital readmission data, and various levels of care outcomes. That set of quality reporting has been foundational for some of the opportunities we have now for even better care going into the future.

Overall — as a nation — we’re at a turning point for care with a combination of artificial intelligence, better care design, much better care connectivity, and various care communication algorithms all steering in the right directions.

If we do this right, care should cost less, be more effective, and be more patient-focused in a relatively short time frame.

The Affordable Care Act — with its array of Accountable Care Organizations and various Better Care Models — should steer us to a golden age for care and give us some of the tools and context we need for that to happen.

We can safely say that the first decade for the Affordable Care Act was an overwhelming success on multiple levels. It makes perfect sense as a context for universal coverage for the country going forward from here.

Obamacare worked.

We should thank and salute the people who designed Obamacare, and we should thank and support the people who are running it and enhancing it now.

It’s directionally correct to do that now.

We will probably see massive positive results a decade from now when we do the 20-year update on Obamacare, because so many things are moving in the right direction and there’s no way that momentum will not continue.

The Affordable Care Act has been a great platform for that progress to happen.

President Obama said that we would have this entire process be foundational and directionally correct, and the right thing to do. He was actually right in both saying that and then putting the first teams and the first processes in place to make it happen in the real world, on his watch.

The people who run CMS now and today understand that complete tool kit. They’re making it better and more affordable every day with their leadership and very intentional and competent steerage.

There’s no reason for us not to be able to take that 4.3 billion health care spending that we have now for the nation and have it give us a future of great and more affordable care.


One key point that we need to add to the puzzle to give us the right future as a nation is a far better understanding of the development processes that exist for children from every group today. Those processes are built into our epigenetic processes as people. We clearly need to do a much better job of having those processes that exist for every child help all of our children.

We will fail hugely as a nation, and we will fail as a people in many settings if we don’t go down that path.

We have massive deficits and huge and painful gaps on income levels, wealth levels, education levels, and health status levels that point to the opportunity we have when children are three months old and three years old to put themselves on the right epigenetic trajectory.

We know that high school dropouts are three times as likely to have diabetic complications, and that being a dropout creates twice as many people going into special needs plans for Medicare and Medicaid. We know that being a dropout makes mortality rates much grimmer for far too many people for every disease and health condition.

We need to help every child.

We have far too much wealth as a country not to help every child get books and other support in those first months and first key years of life that can create equity opportunities for each child, and that clearly cut the number of dropouts significantly everywhere they exist.

Interacting with children in those first months and years is essential.

It can be easy to do, and children absolutely love it when it happens.

Talking and reading to children in those very first weeks, months, and years creates neuron connections by the billions in each child. We don’t do that for far too many children.

More than half of our Medicaid homes didn’t have a single book when we measured that fact — and that is just wrong and extremely inequitable when the other families in their communities have more than 20 books for each child.

So, think about that opportunity.

Let’s have the Affordable Care Act include an addendum that helps every child when they need it the most. And when they love to have it happen.

President Obama probably had far more than 20 books when he was two years old.