The captains and the kings depart, the tumult and the shouting dies, and we and the press have weeks ago moved on from the days of Democratic triumphalism over ObamaCare’s 8 million sign-ups; from ObamaCare’s exhortation that Democrats be “proud” that the ranks of the insured are now about 2% below pre-depression levels. So now is the time to start framing questions for how successful ObamaCare is as policy, now that the original — and absurdly lowballed — metric for success has been met. (That the press was helpfully complicit in accepting sign-ups as a metric for success is one of Obama’s many public relations triumphs.)
And absurdly — pathetically — lowballed ObamaCare’s initial triumph has been. Here’s what CBO projected for sign-ups in 2012:
CBO and JCT now estimate that the ACA, in comparison with prior law before the enactment of the ACA, will reduce the number of nonelderly people without health insurance coverage by 14 million in 2014 and by 29 million or 30 million in the latter part of the coming decade, leaving 30 million nonelderly residents uninsured by the end of the period (see Table 3, at the end of this report). Before the Supreme Court’s decision, the latter number had been 27 million.
Does 14 look like 8 to you? Did I not get the memo? (Now, you can get to 14 million if you also count those who bought private insurance before the deadline, but (1) that’s not how CBO did its calculations, and (2) that says nothing good about the quality of ObamaCare’s site(s) or its policies.)
And there’s a lot else we don’t know. No matter what the Democrats say, all the coverage numbers are still soft. Health Affairs:
Previous coverage status. One question the [HHS summary enrollment] report does not answer is how many of those who chose a plan were previously uninsured. Information on insurance coverage was only collected from FFM applicants who requested financial assistance, and only was only requested as to current insurance coverage at the time of application. Of the 5.18 million individuals who applied for financial assistance and selected a plan in the FFM, 695,011, or 13 percent, indicated that they were insured at the time of application.
HHS acknowledges, however that this number probably undercounts the number of individuals who had coverage prior to applying to the marketplace, and notes that New York has reported that 30 percent of enrollees had prior coverage while Kentucky reported 25 percent. The report also notes Gallup, Rand, and McKinsey data reporting that over half of marketplace enrollees had prior insurance coverage, but observes that Rand, Urban, and Gallup have reported a significant drop in the number of uninsured Americans during the open enrollment period. It will be some time before we know how many uninsured Americans have been covered through the marketplaces.
So, the Democrats are taking a victory lap without having actually crossed the finish line (and after somehow having worked the refs to turn a 140-yard dash into an 80-yard one). Alrighty then. Nevertheless, ObamaCare is, as the “gold standard of medical journalism” NEJM puts it, in a display of realpolitik stunning for anyone who took the Hippocratic Oath, “here to stay.” They explain:
As long as Obama remains in office, he would surely veto any repeal law, and a veto override is inconceivable. Come 2017, outright repeal will remain unlikely for three reasons. First, all major parts of the ACA except the individual mandate [1]are popular — including the insurance-market reforms, the subsidies to make insurance affordable, closure of the drug-benefit “doughnut hole,” and the incentives [although the mandate has been postponed] for most employers to provide affordable insurance as a fringe benefit. Second, lawmakers who support repeal will not want to snatch insurance coverage from an estimated 37 million people who will be insured thanks to the ACA in 2017. Third, repeal would cut into the sales and profits of health care providers and suppliers of all stripes.
Shorter: By 2016, rent seekers will have fastened their sucking mandibles into the body politic sufficiently to make them very hard to dislodge.
Finally, the administration has, yet again, ruled out single payer, at Sylvia Burwell’s confirmation hearings for HHS head. So, the Republicans now have nothing to say, and they’re not saying it:
House Republicans have no scheduled votes or hearings on ObamaCare, signaling a shift in the party’s strategy as the White House rides a wave of good news on the law.
Not a single House committee has announced plans to attack the healthcare law in the coming weeks, and only one panel of jurisdiction commented to The Hill despite repeated inquiries.
GOP campaign committees also declined to say whether they will launch any new efforts on the law.
Truly pathetic. And after all that frothing and stamping. How times did these bozos try for repeal in the House? 42? So, it falls to those in the wilderness to the left of the Democrats to ask questions. Here they are:
- How Many Lives Will ObamaCare Save?
- What is the Actuarial Quality of the ObamaCare “Pool”?
- Will People Be Satisfied with Their Plans Once They Use Them?
- What Will Happpen to Employer-Based Insurance?
- What About the Back End?
- What About Single Payer?
Let’s take each question in turn.
1. How Many Lives Will ObamaCare Save?
Surely the question of lives saved is more important, from a policy perspective, than sign-ups, which involve, after all, filling out a form and making a payment (ka-ching!). And we have a new study from the Annals of Internal Medicine:
Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study
Background: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.
Objective: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.
Design: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.
Setting: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score–defined control group of counties in other states.
Participants: Adults aged 20 to 64 years in Massachusetts and control group counties.
Measurements: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention’s Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.
Results: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (−4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.
This is actually very good news! Translating that into English and doing the arithmetic:
The absolute numbers are also striking. The Congressional Budget Office estimates that ACA will reduce the ranks of uninsured adults by something like 20 million people. I rather heroically extrapolated the authors’ 1/830 estimate to the entire uninsured population across the U.S. This back-of-the-envelope calculation implies that ACA will prevent something like 24,000 deaths every year. That’s almost the number of Americans who die in auto crashes. It’s more than the number who die of AIDS or the number who are murdered every year.
I can’t imagine why the Democrats don’t make this figure a key talking point; they are, after all, perfectly happy to talk about a lesser number of excess deaths in Republican states that didn’t expand Medicaid. Perhaps it’s because ObamaCare, when fully implemented, will only cover half the uninsured, raising the unpleasant question of why Obama and the Democrats, in their signature domestic initiative, are willing to throw 24,000 other lives under the bus?
Of course, with single payer — “Everybody in, nobody out” — this question wouldn’t even arise.
2. What is the Actuarial Quality of the ObamaCare “Pool”?
Again, the numbers are soft, and surely vary randomly (like everything else in ObamaCare) from state to state and even county to county. But we’re beginning to get reports. From North Carolina:
Blue Cross was one of only two companies to offer plans in North Carolina through the online marketplace, and as of May 1, 232,000 people were on Blue Cross marketplace plans. Seventy percent of them didn’t have coverage through Blue Cross previously, the company said.
Initial Blue Cross projections called for 50 percent of the marketplace customers to be 34 years old or younger, but after the enrollment period ended on March 31, the company found that only 32 percent of the people who signed up under the federal health care law fit that profile. Forty percent are ages 35 to 54, and 29 percent are 55 or older.
Younger customers are usually coveted by insurers because they are healthier and can balance out the spending of older customers who consume more medical services. But Blue Cross said even the younger customers who signed up for coverage through the online marketplace are sicker than one would expect.
Thirteen percent of enrollees ages 18 to 34 reported experiencing chronic pain as part of a Blue Cross self-assessment, compared with 8 percent for the age group as a whole. Seven percent have diabetes, compared with 4 percent of the group as a whole, and 24 percent said they have depression, compared with 14 percent for the group as a whole.
“The frequency and types of care ACA customers receive and the conditions for which they are being treated are key factors that will determine future premiums,” Blue Cross said in a statement.
So, as long as North Carolina citizens don’t get sick and don’t use services, their premiums won’t go up. Good to know. Of course, with single payer, this issue doesn’t arise.
3. Will People Be Satisfied with Their Plans Once They Use Them?
First, we should take into account the possibility that Obama’s marketers over-sold the people who signed up in the last minute surge. CJR points to a question that never got asked or answered:
Why are enrollees changing their minds? In the push to get enrollees to sign on the dotted line, sales pitches from the White House and its allies may have overpromised. In the days before the deadline, for example, Organizing for Action, a group that sprang from the president’s reelection campaign network, tweeted like crazy. One example: “For Jake, $15 a month on health care fits into his budget.” But, what did Jake have to pay out-of-pocket? Probably a lot! That wasn’t part of OFA’s sales pitch, which had the flavor of those shoddy sales practices that once drove state attorneys general nuts but now seem perfectly acceptable in the context of selling Obamacare. When people find out they aren’t getting what they bargained for and must pay high amounts of cost-sharing, buyer’s remorse can set in, and they junk their coverage. Reporters should find some of these people and talk to them.
“Reporters should,” but will they? This story, on ObamaCare in NH — therefore with a 2016 subtext — doesn’t get around to mentioning ObamaCare’s narrow networks until paragraph 23, which reads:
To be sure, Obamacare faces unique challenges in New Hampshire. Just one insurance company in the small state offered insurance policies through the program this year, and the insurer doesn’t cover healthcare in 10 of the state’s 26 hospitals, deficits Shaheen and Shea-Porter have been working to fix.
Monopolies with narrow networks are hardly unique to NH. Is it too much to ask that reporters — most of whom have employer-based insurance — pay some attention to the actual policies that ObamaCare sells?
Once again, of course, single payer doesn’t have this problem. Shaheen and Shea-Porter wouldn’t have to be working to “fix” anything.
I’ll cover the remaining three questions tomorrow. If you’ve got experiences with ObamaCare, or the health care industry, to share, please do so in comments!
NOTES
[1] ObamaCare without the individual mandate is Hamlet without the Prince. In a stunning display of either incompetence or kayfabe-like complicity, the Republicans have never made the idea that forcing people to enter a marketplace is wrong — which eventheliberals, at least of few of them, might have agreed with — a key talking point in their attack. Instead, they relied on the knee-jerk appeal of “ZOMG!!! Socialism!!!!” which was plainly false, and then on the collapse of the Federal Exchange, betting the farm that the administration couldn’t resolve a public relations issue by calling on the tech dudes in its base, the creative class. #FAIL.