The next enrollment period for the Affordable Care Act starts in just three weeks, on November 15, so it's assessment time for year one in the traditional media. Here's a
pretty good effort by
The New York Times that uses seven criteria to come to the conclusion that it's pretty much too soon to tell what the real impact of the law will be. Nonetheless, it's a useful exercise that starts out with one flawed premise. See if you can spot it in this introduction:
After a year fully in place, the Affordable Care Act has largely succeeded in delivering on President Obama’s main promises, an analysis by a team of reporters and data researchers shows. But it has also fallen short in some ways and given rise to a powerful conservative backlash.
Yep, there it is, right there in the second sentence. The powerful conservative backlash had absolutely nothing to do with how the law actually functioned. The backlash was baked in since before the law was even passed—before a single vote was taken on it in Congress. If every single person in the U.S. was insured and the law cured cancer, there would have been conservative backlash. Therefore, judging the law by how much conservative opposition there is to it isn't going to tell anyone anything about how it's working.
That aside, they ask and answer some fairly useful questions and miss some important ones, too, particularly since they raise the conservative backlash question. You can find all that below the fold.
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- "Has the percentage of uninsured people been reduced?" That's a pretty easy one, and is and should be the first metric. The law has reduced the number of uninsured Americans by about 25 percent. That's a big deal.
- "Has insurance under the law been affordable?" Another important question and one that's less easily answered. For about 85 percent of people, the subsidies decreased the cost of premiums. For some people who had substandard plans and had to get new ones, premiums increased. But for the majority, plans are what the terms of the law say are "affordable," and premiums are not going to be spiking next year. Now, what's affordable on an individual basis is relative, depending on all of the other costs that families face.
- "Did the Affordable Care Act improve health outcomes?" That's the big question everyone wants answered but it is just simply too soon to tell. One year of increased primary and preventive care just isn't long enough to make those determinations. But there's a glimmer of an indication of where it's working fastest: "An analysis in Health Affairs in August found that mental health treatment among 18- to 25-year-olds who said they had a mental health disorder had increased by more than five percentage points compared with a similar group ages 26 to 35, a significant increase for a particularly vulnerable group." The Oregon Medicaid study, along with a Massachusetts study showed participants reporting better mental health and more economic security. Better mental health for large chunks of the population is also a pretty big deal.
- "Will the online exchanges work better this year than last?" Probably. We don't know yet since they're not open. But the federal government, and the few states that had nightmare experiences (Oregon, Hawaii) have had a year to figure out what went wrong. For their part, the Obama administration is sounding pretty confident.
- "Has the health care industry been helped or hurt by the law?" Helped, by the NYT's analysis: "Wall Street analysts and health care experts say, the industry appears to be largely flourishing, in part because of the additional business the law created." That's evident in large part by how many insurers have decided to join in this year. For-profit hospitals, along with drug companies, are doing quite well on the stock market. An exception in the industry is hospitals in the states that refused Medicaid expansion, which are still having to provide uncompensated care to the uninsured.
- "How has the expansion of Medicaid fared?" Here's the key political question that the NYT frames as some states "balk" at what they fear would create additional costs. Well, no. That was an excuse Republican governors and legislatures used to refuse to play along with the hated Obamacare. That aside:
"States that expanded Medicaid have seen a remarkable reduction in the number of uninsured, a drop of nearly 40 percent," said Stan Dorn, a health policy expert at the Urban Institute, a nonprofit research group. "That compares with a reduction of less than 10 percent in states that have not expanded.
Upwards of 6.3 million people are left out because they fall in the Medicaid gap—they make too much to qualify for Medicaid in their states, and too little to meet the subsidy level for private insurance on the exchange.
- "Has the law contributed to a slowdown in healthcare spending?" Maybe? Health care spending is slowing down, a lot. Particularly in Medicare, where the government has more direct control and which has slowed down to the point that it's saving the country more money than any of the deficit reduction plans that have been proposed in the past several years—more than Paul Ryan, more than the Catfood Commission. But whether that slowdown can be primarily attributed to Obamacare isn't clear. Most analysts, though, say it is a definite factor.
Here are a few questions the Times might want to take up in a follow-up story: What, in all of the above information, accounts for conservative backlash? What happens to all of those people now with coverage if the Republicans have their way and repeal the law? What's the Republican plan for replacing it, if indeed they ever get to repeal? Since we're just one week away from an election that could lead to a Republican takeover of the Senate, those might be some questions worth dwelling on.