Nearly six years after its enactment, the Affordable Care Act remains a hot issue in the presidential race – in both parties.

“Our health care is a horror show,” said GOP candidate Donald Trump at the Republican debate in South Carolina in December. Texas Sen. Ted Cruz, winner of the Iowa caucuses, said at the debate in Des Moines that the health law has been “a disaster,” adding it’s “the biggest job-killer in our country.”

Democrats largely support the law, but even they can’t agree on how to fix its problems. Hillary Clinton said at the Jan. 25 town hall on CNN that she wants to “build on the ACA. Get costs down, but improve it, get to 100 percent coverage.”

Clinton’s rival for the nomination, Vermont Sen. Bernie Sanders, acknowledged that “the Affordable Care Act has done a lot of good things,” but added that “the United States today is the only major country on earth that doesn’t guarantee health care to all people as a right.” Sanders is pushing a government-run “Medicare for All” plan instead.

In some cases candidates are bending the truth. But praise and criticisms of the law can be accurate. That’s because the health law is so big and sweeping that it has had effects both positive and negative.

Here is a brief guide to some things the health law has – and has not – accomplished since it was signed by President Barack Obama in 2010.

CLAIM: The law has increased the number of people with health insurance coverage.

This is true, no matter what measure you use. The Census Bureau and polling firm Gallup both found substantial drops in the percentage of people without health insurance after the majority of the law’s coverage expansions took effect in 2014.

COUNTER-CLAIM: There are still millions of Americans who don’t have insurance.

This is also true. Even though approximately 90 percent of Americans now have insurance, that remaining 10 percent amounts to more than 30 million people.

Millions aren’t eligible for coverage under the law because they’re not in the U.S. legally. Another 3 million are in the so-called Medicaid gap, meaning they would be eligible for Medicaid under the ACA except their states opted not to accept the expansion after the Supreme Court effectively ruled the expansion optional.

Still others are eligible to purchase coverage on a health insurance exchange, but either can’t afford it, don’t think the insurance available offers a good value, or don’t know they are legally required to obtain it. An estimated 7.5 million Americans paid a fine to the IRS for failing to get covered in 2014; millions more were exempt from the requirement and didn’t have coverage.

In recognition of the fact that enrollment has been smaller than expected, the Congressional Budget Office recently lowered its projections for those who will buy insurance under the law from 21 million to 13 million in 2016.

CLAIM: The ACA has fixed the dysfunctional individual insurance market.

Prior to the passage of the health law, millions of people who didn’t have work-based or government coverage were shut out of buying their own insurance because they had been sick or because the coverage offered did not cover the services they needed.

The law aimed to address the problems in the individual market in several ways, including requiring insurers to sell to those with preexisting conditions at the same price as healthier people; standardizing the benefits package; and limiting the size of deductibles. Tax credits were made available in order to help people afford coverage. And the law created insurance exchanges intended to help consumers compare, choose, sign up and pay for health insurance.

How well these changes succeeded in stabilizing the market isn’t clear. What is clear is that more people are now insured through the market.

COUNTER-CLAIM: The ACA has made the individual market worse.

All is not well in the individual market. Even with help paying premiums, many moderate-income Americans are finding that their deductibles and copayments are so high they cannot afford to use their insurance.

In other cases, individuals can get insurance they can afford to use, but it doesn’t include their regular doctors and hospitals. In fact, plans that do offer coverage outside of the insurer’s network are becoming harder to find and more expensive.

That change affected Cruz, who initially claimed his private insurance had been cancelled. In fact, his insurer had stopped offering his broad-choice plan and automatically transferred him to a narrow-network product.

CLAIM: The ACA has improved the Medicare program.

While most of the law was aimed at those without insurance, lawmakers also took the opportunity to beef up some benefits for the 55 million Americans in the Medicare program.

Medicare enrollees got new coverage for preventive services and annual checkups, and those with high prescription drug expenses got help to fill the “doughnut hole” gap left by the 2003 Medicare drug program.

Over the longer term, the law created several payment experiments intended to improve the quality of care Medicare patients receive and lower costs. These include efforts to prevent patients from going back to the hospital after they’ve been discharged.

COUNTER-CLAIM: The ACA has not saved money for Medicare.

The rate of increase in Medicare spending has slowed since the health law was passed in 2010. But it’s not clear how much of that can be attributed to the law, aside from some provisions that actually cut payments to hospitals and other health providers.

And some of the most highly anticipated projects, including accountable care organizations that are paid bonuses for keeping Medicare patients healthy and lowering spending, have not so far shown very good results.

CLAIM: The ACA has killed jobs.

One of Republicans’ favorite talking points – that the health law would depress employment – has turned out not to be the case.

An analysis in 2015 by the Urban Institute found that the health law “had virtually no adverse effect on labor force participation; employment; the probability of part-time work; and hours worked per week by nonelderly adults.”

While there would be fewer people in the workforce due to the law, the Congressional Budget Office found in 2014 that “almost entirely” stems from voluntary actions by workers who could quit because they no longer depended on their jobs for insurance — now they could buy it on their own.

CLAIM: The ACA has slowed overall health spending.

The White House trumpeted the fact that health spending grew at its slowest rates ever between 2010 and 2013. But health policy analysts are still engaged in a lively debate about how much of the slowdown was attributable to the recession, to the health law and to other changes in the health care system.

Meanwhile, the rate of spending has begun to accelerate again, jumping from a 2.9 percent increase in 2013 to 5.3 percent in 2014. That has occurred as millions more Americans gained access to health care through the law.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Julie Rovner is on Twitter: @jrovner.

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The cystic fibrosis drug Orkambi can help people with specific genetic mutations breathe better, but treatment with the pill comes with a hefty sticker price — $259,000 a year.

Orkambi, which was approved by the Food and Drug Administration last July, is expected to take almost $36 million from California’s general fund this fiscal year and next. That cost estimate doesn’t include any discounts the state may receive from drug manufacturers.

Seventy-four Californians with health coverage under the Department of Health Care Services are expected to receive the drug in the current fiscal year. In the next one, 220 people are expected to get it, some of whom may be the same patients as this year.

Orkambi is listed on the specialty tier of drug categories in some private health plans. That category is typically reserved for high-cost drugs or, in the federal government’s view, for drugs that cost more than $600 a month and are used by a small proportion of patients.

Specialty drugs are already proving to be a financial burden on one California agency, the California Public Employees’ Retirement System, which purchases health benefits for active and retired state workers. CalPERS says that specialty drugs made up less than 1 percent of all prescriptions for its members but accounted for 30 percent of the total drug costs in 2014.

Drugmakers say the health benefits from specialty drugs justify their cost.
“Patients are gaining access to medicines that are better treating their diseases or frankly even curing them,” said Priscilla VanderVeer, deputy vice president of communications at the Pharmaceutical Research and Manufacturers of America. “Patients are now healthier. They’re more productive. They’re functioning.”

VanderVeer said companies price drugs not just on the cost of production, but on the value the industry believes the drug brings to the health care system, such as efficacy, improvements in quality of life or length of life and the extent to which the medical need for a drug has gone unmet.

The price of the drug also accounts for the cost of developing other drugs and the high risk that a particular drug won’t make it to market, VanderVeer said. Only 12 percent of drugs that go through clinical trials get approved, according to PhRMA.

Finally, she said, the sticker price doesn’t reflect the final price paid for the drug, which can be heavily discounted through negotiations or because of mandated rebates for Medicaid programs.

Drugmakers are following the money, said Joel Hay, professor of pharmaceutical economics and policy at University of Southern California. Companies invest in specialty drugs that target a small population because their high price tags can be spread over a large insurance pool, he said.

Even though specialty drugs are “ridiculously expensive per treatment episode,” Hay said, the cost for each member in a health plan is “just a few cents.” Raising the price 10 cents on a diabetes drug, for example, would have a bigger budget impact, he said, because more people have diabetes than cystic fibrosis.

Hay says manufacturers are now less inclined to invest in drugs that treat millions of people, because there is more pushback on price. “Drug companies are for-profit companies obligated to make money for their stockholders,” Hay said. “They’re not virtuous charitable organizations.”

Drugmakers are also investing more in treating uncommon illnesses because there is less competition and therefore more opportunity for profit, said Dr. Helene Lipton, professor of health policy at the School of Pharmacy and Institute for Health Policy Studies at the University of California, San Francisco.

The high price of the drugs affects patients, she noted, because health plans put controls on the drugs so that they’re used as a last resort.

“That may mean going through two or more rounds of care with other medications before being able to use the specialty drug,” Lipton said.

Still, it’s not just specialty drugs that are straining health plans’ budgets, said Steve Miller, chief medical officer at Express Scripts, a pharmaceutical benefits manager that negotiates drug coverage for 7.5 million Californians.

“The price of drugs is just continuing to go up,” said Miller, explaining that the trend is due to both new high-cost drugs coming on the market, and mark-ups of old drugs.

There has been an explosion of drugs costing $100,000 a year over the past decade, for things like cystic fibrosis and cancer, Miller said. And there was a 127 percent price increase of branded drugs that had been on the market between 2008 and 2014, he says.

A California ballot initiative scheduled to go before voters this November aims to rein in drug costs by limiting the amount the state pays for a drug to no more than the lowest price paid for the same drug by the U.S. Department of Veterans Affairs.

A version of this story appeared first on KQED’s State of Health blog. CALmatters is a nonprofit journalism venture dedicated to explaining state policies and politics. Pauline Bartolone wrote this article while participating in the California Data Fellowship, a program of the Center for Health Journalism at USC’s Annenberg School of Journalism.

Barolone will be exploring how the cost of specialty drugs’ affects patient access. If you are a chronic disease patient who is either taking a specialty drug or having difficulty getting the right one, she would like to hear from you. Reach her on Twitter @pbartolone or pauline@calmatters.org.

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