Obamacare had one of the worst launches ever for a government program. The New York Times wrote a front-page piece in November 2013 with the headline “Health Law Rollout’s Stumbles Draw Parallels to Bush’s Hurricane Response.” Thousands of Americans, many of whom had long waited to purchase health insurance, found themselves unable to log onto healthcare.gov. President Obama was forced to repeatedly acknowledge failures in one of his signature initiatives.
A year later, as the Obama administration starts year two of the implementation of the Affordable Care Act, the story of the health care law is much different. There are a growing number of signs the law is working as intended, and it has in turn receded as a political issue.
Here’s a closer look:
1. Millions of Americans are newly-insured
One of the principal goals of the Affordable Care Act, expanding the number of people with health insurance, has unquestionably been accomplished. A non-partisan health policy organization called the Commonwealth Fund estimated that 9.5 million people gained insurance over the last year. The New England Journal of Medicine put the number at 10.3 million. The Urban Institute said it is more than 8 million. Gallup estimates that 5 percent of Americans were newly-insured in 2014.
The story of exactly how this expansion happened is more complicated. Much of the attention last year was on whether 7 million Americans would enroll through so-called exchanges that were run through the federal government, or in states. But much of the expansion of insurance actually came through less-publicized parts of the law, the provision that requires insurance companies to allow people between ages 18 and 26 to stay on their parents’ plans, parts of the law that encouraged employers to offer coverage to their workers, and most importantly, a vast expansion of Medicaid.
2. Lots of potential problems never became actual problems
In the midst of the challenges of healthcare.gov last fall, Republicans, some liberals and the press (myself included) suggested a number of potential problems that could cripple the health care law: only older, sicker people would enroll; younger Americans would not participate in the program because they felt they were "young and invincible"; insurance prices would skyrocket because the exchanges skewed toward older and sicker Americans; only people who already had insurance would enroll; the enrollment numbers were misleading because a sizable number of people would never pay for their plans; or, Latinos would be too scared to enroll, because it might highlight their immigrant status, or that of their relatives.
None of this came to pass. The Commonwealth Fund study suggested the largest growth in people getting insurance were those between ages 18 and 34, who are disproportionately uninsured. Latinos are also gaining insurance coverage in high numbers. The balance between younger and older people seems sufficient for health insurance companies, who have voted with their feet, as the U.S. government has estimated a 25 percent increase in the number of insurers offering ACA plans this fall compared to last year.
About 700,000 of the estimated 8 million people who enrolled in ACA plans are no longer in the program (not paying their premiums is one way this could happen), according to U.S. government data, a sizable number, but also less than 10 percent of the total enrollees. (In other words, 90 percent of people did pay their premiums.)
3. Pro-Obamacare states reduced their uninsured rate much more than anti-Obamacare states
The U.S. government estimates that Medicaid enrollment went up by about 440,000 in Kentucky and 227,000 in Arkansas over the last year. On the other hand, it went down about 30,000 in Alabama and increased just 135,000 in Texas, a state with almost four times the population of Arkansas and Kentucky combined.
This is not about the politics of individual people in those states. President Obama was soundly defeated in 2012 in all four of these states and remains unpopular.
But Democratic governors in Arkansas and Kentucky not only accepted federal funding for Medicaid through the law, but actively tried to enroll people on health insurance plans, with tactics ranging from holding events at bourbon festivals (in Kentucky), to using a direct mail campaign that allows people to enroll without going on-line (in Arkansas).
The governors of Alabama and Texas actively opposed the program.
Data from the Kaiser Family Foundation found that the states that enrolled the highest percentage of their residents through the health care exchanges also had liberal governors: Vermont, California and Rhode Island.
4. Many challenges remain for the American health care system
Obamacare is designed to reduce American health care costs overall, improve Americans’ health, offer insurance to more than 25 million Americans and reduce disparities in health care and coverage between the rich and the poor, and minorities and whites.
It’s simply too soon to say if it has accomplished many of these goals. It’s important to note that Kaiser estimates that 28 million people were eligible to get subsidized health insurance last year, and 8 million purchased it.
That means 20 million Americans did not get insurance despite an intense public campaign from the White House, a very long period to buy insurance (from October through April), near constant attention on the health care law from the news media, and the threat of a fine if citizens did not purchase insurance.
Surveys show that large numbers of the uninsured either had not heard of the law, or did not feel it reduced prices enough for them to purchase insurance. And the uninsured remain disproportionately young, non-white and lower-income.
"It's not that they made a conscious decision to be insured," said Anne Filipic, president of Enroll America, a group does on-the-ground organizing to encourage people to get Obamacare plans. "We saw a really significant gap in knowledge. Even with all the work and all the coverage, for some reason some people didn't get the information. That fundamentally means they are hard to reach."
The Congressional Budget Office has estimated that 7 million people will newly enroll in health insurance this year. That could be a challenging number to reach, because the enrollment period is from November 15 to February 15 this year, three months shorter than last year.
And there remain questions about exactly what kind of coverage people are getting. In its study, the Commonwealth Fund said “75% of people who were previously uninsured and had used their new coverage said they would not have been able to get this care prior to gaining insurance.”
But The New York Times, citing a U.S. government report, wrote this week: “Medicaid patients often find that they must wait for months or travel long distances to see a doctor.”
5. Republicans still hate “Obamacare”
Remember how Obamacare has vastly reduced the number of uninsured in Arkansas and Kentucky? The Democratic U.S. Senate candidates in those states almost never speak of this, wary of conservative-leaning voters in those states who may have even enrolled in the health care program, but still view it unfavorably because it is associated with President Obama.
Asa Hutchinson, the Republican who is likely to replace Democrat Mike Beebe as governor of Arkansas, has been lukewarm about the state continuing its participation in the health care law.
Greg Abbott, the Republican candidate and likely next governor of Texas, has already said he will continue Rick Perry’s opposition to the law, a huge move since Texas is a vast state with more than 6 million uninsured.
Twenty-three states have refused to expand their Medicaid programs. All either have Republican governors, or a GOP-legislature that is opposed to the program.
“If you are a Republican, you don’t like this law. If you’re a Democrat, you support it. Nothing has changed,” said Drew Altman, president of Kaiser.
“The debate about the ACA is not a debate about the ACA. It’s a debate about bigger things argued through the ACA,” he added.