In a peer-reviewed article published in JAMA, President Barack Obama assessed how the healthcare law so closely associated with him has affected the healthcare system—and how he believes it could be improved.

Obama argues the law has achieved several of its main goals, like reducing the number of Americans without health insurance to 9.1 percent in 2015, according to the National Health Interview Survey, and expanding value-based care.

“The law created the Center for Medicare and Medicaid Innovation (CMMI) to test alternative payment models and bring them to scale if they are successful, as well as a permanent ACO program in Medicare,” Obama wrote. “Today, an estimated 30% of traditional Medicare payments flow through alternative payment models that broaden the focus of payment beyond individual services or a particular entity, up from essentially none in 2010. These models are also spreading rapidly in the private sector, and their spread will likely be accelerated by the physician payment reforms in MACRA.”

Obama also writes the ACA deserves some of the credit for reducing the rates of hospital-acquired illnesses and 30-day readmissions for Medicare patients.

After recapping what he sees as the law’s successes, he offers his own recommendations for what the next steps in healthcare reform should be.

First, he characterizes the rise in premiums and the numbers of insurer leaving the exchanges for 2017 as a sign that “both insurers and policy makers are still learning about the dynamics of an insurance market that includes all people regardless of any preexisting conditions, and further adjustments and recalibrations will likely be needed.”

An important part of those adjustments, he writes, is getting the 19 states which chose not to expand Medicaid to do so.

Second, he argues for more financial assistance from Congress to reach those who remain uninsured based on affordability of coverage.

His third set of recommendations appear to be the most striking. To address the limited number of exchange options in some areas, he suggests Congress reconsider a controversial aspect of healthcare reform which wasn’t included in the final version of the ACA: a Medicare-like public plan.

“Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited. Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government,” Obama wrote.

His last recommendation is for Congress to focus on ways to lower the cost of prescription drugs, like the proposed Medicare Part B demonstration which has drawn opposition from both Republicans and Democrats.

In the conclusion to the editorial, Obama asks future policy makers to learn from the struggles of passing and implementing the ACA by avoiding “hyperpartisanship,” compromising when sides offer very different solutions to the same issues (“the single-payer model vs. government vouchers for all”) and not allowing industry groups to dictate policy.

“We worked successfully with some health care organizations and groups, such as major hospital associations, to redirect excessive Medicare payments to federal subsidies for the uninsured. Yet others, like the pharmaceutical industry, oppose any change to drug pricing, no matter how justifiable and modest, because they believe it threatens their profits,” Obama wrote. “We need to continue to tackle special interest dollars in politics. But we also need to reinforce the sense of mission in health care that brought us an affordable polio vaccine and widely available penicillin.”

Obama isn't the first sitting president to write in JAMA. George W. Bush once made his case for healthcare reform in the journal, though Obama's contribution is said to be the first full-fledged presidential article, complete with a conflict of interest disclosure. 

You can read the full editorial at the JAMA website.