Obamacare: good to poor to who knows what

Sam Smith - Obamacare became such a contentious issue, and the bill itself was so inordinately complicated, that to this day it is hard to get a fair accounting of the measure. As we pointed out as it was being debated, one could find in the legislation the fine, the bad and the unpredictable. Five years later it hasn’t gotten any better.

One good summary that we’ve seen is by Dr John Geyman ofPhysicians for a National Health Program, who noted:

• Federal health insurance exchanges have been set up in 37 states through the HealthCare.gov. marketplace, together with state exchanges in the other states.
• After the first enrollment period ended in February 2014, there were 9.5 million fewer uninsured, with the uninsured rate among adults dropping from 20 percent to 15 percent; the uninsured rate for people in poverty fell from 28 percent to 17 percent in states that expanded Medicaid, but from only 38 percent to 36 percent in non-expanding states.
• In the second open enrollment period ending in February 2015, about 11 million people signed up, three-fourths in federal exchanges and the others through state-run exchanges; this number, however, includes many who were automatically re-enrolled from the first year and will likely drop a bit in coming months for failure to pay premiums, as occurred after the end of the first enrollment period.
• About 85 percent of the newly insured are expected to be eligible for subsidies, unless the U.S. Supreme Court rules them out, in which case it is expected that as many as 8 million will drop coverage in a chain reaction that would send premiums soaring.

Although these sign-ups reflect significant progress, the ACA will fall far short of its goals, as shown by these examples:

• At best, there will still be at least 30 million uninsured in 2019, plus  unknown millions more, especially those in the young adult 18-34 age  range who find the costs of insurance too high.
• As a result of 22 states choosing not to expand Medicaid, almost 5  million people fall into the “Medicaid coverage gap,” earning too  much to be covered by existing Medicaid and too little to be eligible for subsidies…
•  Small businesses with less than 50 full-time employees, though eligible to purchase coverage through the Small Business Health Options Program, have shown little interest in doing so, with many instead  dropping previous coverage and offering raises to employees as they seek coverage on the exchanges.
• As insurers seek to contract with lower-cost hospitals and physicians, they disrupt many patients’ choices and relationships with them. Networks are shrinking all over the country, with many patients unaware of whether their doctors and hospitals are in-network, vulnerable to high out-of-network deductibles and out-of pocket costs, and often having to change physicians.
• With a shortage of at least 45,000 primary care physicians, and with only 20 percent of U.S. physicians practicing primary care, it is difficult for many people newly insured under the ACA to gain access to comprehensive care; a 2013 study found that only two-thirds of U.S. primary care physicians would accept new Medicaid patients, partly due to low reimbursement rates; and a December 2014 report found that one-half of 1,800 physicians listed by 200 private Medicaid plans in 32 states would not accept new Medicaid patients or were unavailable at their last known address.
• In order to gain eligibility for subsidies, most people signing up for coverage on the exchanges select “silver” plans with actuarial values of 70 percent; but that still leaves them responsible for 30 percent of their health care costs, which pose a financial hardship for many.
• For many patients insured through the exchanges, constant changes in coverage and networks often result in surprise bills that are so confusing that they avoid going to the doctor.
• While the ACA requires coverage of “pediatric services,” they are so poorly defined that most states exclude coverage of children with special health care needs.
• The ACA has been very friendly to the health insurance industry, allowing them wide latitude to game expanded markets in their pursuit of profits. These examples make the point—permitting insurers to exclude 70 percent of essential community providers from their networks, allowing them to market limited benefit plans that pay a one-time cash benefit of as little as $10,000 or $20,000 upon diagnosis of a critical illness, and protecting them from losing money through a “risk corridor” program.

Another good listing of pros and cons can be found here

One thing that has been almost totally missed in the discussion has been the fact that approximately half of the benefits of the measure are actually an expansion of Medicaid, a 50 year old Great Society measure that Americans take for granted. In short, a half the bill is really Obamacare, the rest is really just expanded Johnsoncare.

In fact, there is no probability that a Lyndon Johnson, or even a Richard Nixon, would have written a measure as needlessly complex, mushy, tone deaf, and politically alienating as  Obamacare.

In a summary of a book on the topic, the Columbia UniversityPress noted:

In 1965, the United States government enacted legislation to provide low-income individuals with quality health care and related services. Initially viewed as the friendless stepchild of Medicare, Medicaid has grown exponentially since its inception, becoming a formidable force of its own. Funded jointly by the national government and each of the fifty states, the program is now the fourth most expensive item in the federal budget and the second largest category of spending for almost every state.

In dramatic contrast with the story of Obamacare, according to the Kaiser Family Foundation:

More than half of states implemented a Medicaid program within the first year federal funding became available, and nearly  all states were participating in Medicaid within four years, even though participation required substantial state investment. Over time, states have met new federal requirements to extend Medicaid coverage and expanded beyond minimum coverage levels at the regular federal matching rate.

Interestingly, in 2007 Public Citizen did an analysis of Medicaid and found that five of the ten best states for quality of care are now among the 19 that have so far rejected the expansion Medicaid under Obamacare.

With the Obama administration, however, and its bullying approach towards state and local power as well as decision making in general, Medicaid became no longer an assumed consensus but one more target of bitter debate. And the roots were not in ideology but in the contempt the Obama crowd shows towards those who are not themselves.

Meanwhile, both sides neglect to mention important things. For conservatives, these included coverage under parents’ insurance for older children. For liberals these include not mentioning, as the Heritage Foundation has pointed out, that “while enrollment in individual market coverage grew by almost 6.3 million, 61 percent of that gain was offset by a reduction of nearly 3.8 million individuals with employer-sponsored coverage.” There has been a surprising liberal indifference towards those too wealthy for Medicaid but for whom required insurance or the fine for lack thereof is a significant factor in their already difficult budgets. And a public option, that would have allowed citizens to buy into Medicare, was backed by Obama when he ran for president but was killed in Congress after the president had dismissed as a "sliver" of his reform.

In short, anyone who tells you how great or bad Obamacare is isn’t telling you the whole truth. And watch out: there are more surprises coming.