I spend a fair amount of time trying to convince people that even if the Affordable Care Act holds, much remains to do to improve the health care system. This stems from a belief that even if we improve access, costs are still too high and quality is still too low. Anyone that needs convincing of this need only look to Massachusetts.

Let’s remember that Massachusetts has had some of the most comprehensive health care reform around. Its insurance regulations, for better or worse, closely resemble those of the Affordable Care Act . Massachusetts has the highest rate of insurance in the nation, and thus the lowest numbers of uninsured. So it’s worth looking at Massachusetts as an example of what might occur under the ACA nationwide.

To that end, a number of organizations recently teamed up to look at how "sick" adults rated the cost and quality of care in the state:

This poll examines the views of sick adults in Massachusetts regarding the costs and quality of health care in the state as well as their perceptions about their own health care in the past year. "Sick" adults in Massachusetts (27% of adults) are defined as those who said they had a serious illness, medical condition, injury, or disability requiring a lot of medical care or who had been hospitalized overnight in the previous 12 months. Focusing on the experiences and opinions of those who have had significant recent medical care yields special insight into the current problems and opportunities facing Massachusetts’ health care system.

After all, it’s "sick" people whom the health care system is supposed to serve.

The results are not very encouraging. About half of those surveyed reported that the cost of care is a "very serious" problem in Massachusetts. An additional 28% thought they were a "somewhat serious" problem. Almost two-thirds thought that health care costs had gotten worse in the last five years.

To those of us who follow health care reform closely, this isn’t a huge surprise. After all, missing from the Massachusetts reform passed by Governor Romney are any sort of cost controls. Whatever your feelings are about the chances of the ACA succeeding in bending the cost curve, the cost containment reforms in the federal legislation are more than those passed at the state level.

What is surprising, though, are the disappointing scores given to quality in the state of Massachusetts. After all, the state is home to some of the most highly regarded medical facilities and schools in the world. And yet, more than a third of "sick" adults reported that the quality of health care in the state is a very serious or somewhat serious problem. Almost two thirds felt that the quality of care had gotten worse (21%) or stayed the same (44%) in the last five years. The number one reason given for poor quality was "some people not being able to afford to get the tests or drugs they need".

There are three pillars that are important to discuss whenever one talks about a health care system. Those are access, cost, and quality. Often, improving any one (or two) results in worsening of a third. The Affordable care Act recognizes that limitation. Sure, it will increase access, reducing the number of uninsured in the United States by tens of millions of people. That improved access costs money, though, to the tune of nearly a trillion dollars in the first decade. By raising revenues and cutting spending, the law hopes to come up with that trillion dollars without increasing the deficit. We all should recognize, though, that nothing is free. Improving access costs money.

The lesson to be learned from this survey is that we need to realize that we’re already starting from way behind. The state with the best access overall is suffering from the highest costs, and sub-optimal quality. Improving either of those two is going to be even harder than fixing access was.

We are days away from a Supreme Court decision that could rock whatever foundations we’ve established for health care reform. Should the law hold, we still have far to go to rein in health care costs that are potentially devastating to our fiscal future, and far to go to improve our shockingly poor quality scores. If the law should be struck down, those two facts remain true, only we will have done nothing to improve the problems tens of millions of people face with respect to access.

No matter what happens, health care reform is far from over.

Dr. Aaron E. Carroll is an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll. As part of our ongoing effort to raise awareness of health services research and increase its application in policy and practice, AcademyHealth has partnered with Austin Frakt, Ph.D., and Aaron Carroll, M.D., M.S., to contribute posts on the subjects of health care costs, delivery system transformation, and public and population health – areas AcademyHealth has identified as a priority in the current policy environment. As regular contributors, they’ll be discussing current events with an eye toward how new and existing research informs the issues.