First, our beloved U.S. health care system, pre-ACA, is a moral, ethical, humanitarian, and economic disgrace. No other advanced nation on earth permits its citizens to suffer financial ruin because they get sick. No other advanced nation leaves so many citizens with no financial protection from the cost of illness, with as many as 45,000 deaths each year due to lack of health insurance. No other nation spends as much on medical care services as we do, and for such mediocre results.

Readers here may have noticed that I spend a lot of time writing about the Affordable Care Act (aka: ACA/ObamaCare). On the occasion of the second anniversary of the law's signing on March 23, 2010, let me explain, as concisely as possible, why.

Second, the ACA, while far from perfect, is the best opportunity in this generation to move our health system in a new direction. In my 27 years of watching and studying, I have never seen the level of innovation, change, and experimentation for improvement as we have seen since March 2010. (See Sarah Kliff in today's Washington Post.) This is true for private insurance, Medicaid, Medicare, the medical delivery system, prevention & wellness, workforce, fraud and abuse, pharmaceutical innovation, and much more. Times such as this don't happen often, and never last. The forces of inertia always come roaring back. We need to continue pushing as much and as hard as possible while it's possible.

Third, the ACA was not written in stone and, if it survives, will be constantly improved and revised. Its two peers, the 1935 Social Security Act and the 1965 Medicare/Medicaid Act, have been constantly altered in small, medium, and large ways throughout their histories -- the ACA itself implements the biggest changes in Medicare and Medicaid since 1965. Signing a law is the end of one legislative process, and the beginning of a robust, multi-faceted new effort at continuous policy improvement. If the ACA goes away, it will take another generation or more for our society to face up to the deep and systemic problems the law enables us to address.

Fourth, though the ACA was the not the best law Congress could have written, it is close to the best law that could have been produced by Congress in 2009-10. Lots of smart people had their own ideas for how to reform U.S. health care, and none of them could have achieved 50% plus one in the U.S. House and 60 votes in the U.S. Senate. The window of opportunity for Congress to tackle a problem of this complexity and magnitude has come and gone -- the ACA is our best opportunity to move forward.

Fifth, the law is already helping many millions of Americans in numerous ways. Here are just a few: 2.5 million young adults are now enrolled in their parents' health insurance; 105 million Americans no longer face lifetime benefit caps on their insurance plans; 86 million Americans, including those in Medicare and private coverage, have received free preventive services such as check-ups and cancer screenings; 17 million children can no longer be denied coverage because of pre-existing conditions; 3.6 million Medicare seniors have received savings on prescription drugs because of the closing of the so-called "donut hole;" in 2011, 360,000 small employers used the small employer tax credit to make insurance more affordable for their two million employees. On and on...

Sixth, beyond birth control, the ACA represents the biggest improvement in women's health ever, and beginning in 2014 will end the practice of charging women higher health insurance premiums based solely on their gender -- in other words, being female will no longer be a legal pre-existing medical condition.

Seventh, as Cong. James Clyburn (D-SC) said two years ago, the ACA is "the civil rights act for the 21st century," representing the biggest improvement in the health and well-being of non-white Americans ever.

Eighth, unlike the 2003 Medicare Modernization Act passed by a Republican President and Republican-controlled Congress, which will add about one trillion (yes "trillion") to the federal deficit between 2010-19, the ACA is fully financed and will reduce the federal deficit -- the Congressional Budget Office, this week, estimated the law will reduce the deficit by at least $50B more than they projected two years ago.

Ninth, opponents to the law point to no real life individual who has been harmed through the implementation of the law, and have relied on deliberate disinformation and distortions (death panels, new tax on home sales, on and on) to promote their opposition.

Tenth, this is not a moment in America's history when I can sit on my hands and be quiet. The gains to be realized through full implementation and the losses to be suffered through repeal are of fundamental importance to what kind of a society America will be.

And so at least through November 6th...

Bang, bang, bang!

