Rates of Uninsured by State Before & After Obamacare

To what extent is Obamacare succeeding in reducing the number of uninsured adults?

The best estimates suggest that more than 20 million Americans have benefited from the insurance expansion provisions of the Affordable Care Act (aka: ACA, Obamacare), and that approximately 10 million of those were previously uninsured (Commonwealth Fund and Harvard School of Public Health estimates). The Congressional Budget Office estimates that by 2016-17, about 25 million formerlyuninsured Americans will have coverage because of the ACA's expansion. The expansion is expected to level off and stabilize after that.

Going forward, do you think the law will continue to reduce the number of uninsured adults? Will all Americans one day be covered?

The expansion is predicted to level off by 2017 with about 30 million or so remaining uninsured. But this will not be the pre-ACA status quo for these remaining uninsured. The largest portion -- the lowest income -- will be eligible and able to sign up for Medicaid virtually anytime, including at the hospital or community health center when they require medical care. The second largest portion will be uninsured adults who choose not to sign up for coverage guaranteed to them under the ACA -- they will be able to do so every year during the 3-month open enrollment period between October 1 and December 31, and insurers will not be able to discriminate against them because they have pre-existing medical conditions. The third large group of uninsured will be undocumented immigrants who are not entitled to new benefits under the ACA -- hopefully, their needs will be addressed when Congress summons the political will to address immigration reform.

So the ACA is not, and never was, 'universal' health insurance; it is, however, guaranteed health insurance for all American citizens and documented immigrants who choose to take advantage of its provisions. That is an enormous step forward for all those who will obtain coverage, for those who do not take advantage of the law now, and for all Americans who get a better and fairer health care system because of the ACA.

What do you think are the major obstacles facing Obamacare's implementation in the near term? In the long term?

The critical implementation date for the ACA was January 1 2014. On that date, the Medicaid expansions(in willing states), the private insurance subsidies, the insurance market changes especially guaranteed issue and elimination of pre-existing conditions, and the individual mandate, all changed from being hypothetical to real -- and any repeal by Congress changed from eliminating hypothetical to real benefits for millions and millions of American citizens. There were fatal threats to the success of the ACA -- such as the Supreme Court challenge and the 2012 presidential election. Those are over. The law will be changed and improved as we move forward, and the existential threats are now in the past.

A major challenge moving forward is the 24 states that have yet to approve the Medicaid expansion, denying affordable coverage to more than 5 million low income Americans. As the furor over Obamacare subsides, more and more of these states will join the expansion. I predict that by 2020, all 50 states will be part of the ACA's Medicaid expansion.

What do you think is the most common misconception people have about Obamacare?

According to Jimmy Kimmel, one of the major misconceptions is that most Americans don't understand that the 'Affordable Care Act' and 'Obamacare' are one and the same thing. The ACA has been subjected to one of the most expensive and extensive delegitimization campaigns that any new law has faced in US history. The ACA is not a socialist takeover of the insurance industry -- indeed, the industry is a winnerunder the law. It does not represent the destruction of the patient-physician relationship -- which has been under extreme duress for more than 20 years now.

Of the world's 30 leading developed nations, the U.S. is the only one, the last one, where every day someof our fellow citizens suffer complete financial ruin because they or a member of their family experience serious illness or injury. The ACA is helping, finally, to end that reality for most Americans. That's a good thing.

To what extent is Obamacare succeeding in reducing the number of uninsured adults?

All the evidence to date shows that the Affordable Care Act is significantly reducing the number of the uninsured. Polling data indicates that the number of uninsured has been reduced by 5 to 9 million.

Going forward, do you think the law will continue to reduce the number of uninsured adults? Will all Americans one day be covered?

The law will continue to reduce the number of uninsured over the next several years. Without further reform, however, we will not reach the point where every American is covered.

What do you think are the major obstacles facing Obamacare's implementation in the near term? In the long term?

The biggest obstacle is the refusal of half the states to expand Medicaid. This is purely a political problem. It is to be hoped that at some point human need and economic reality will become more important that politics. The technical challenge of making the exchanges full operational and the difficulty of educating the public as to the availability of coverage are also challenges, at least in the short run.

What do you think is the most common misconception people have about Obamacare?

That it is a government takeover of health care. In fact, it is a heroic attempt to make markets work in healthcare as they have not in the past.

To what extent is Obamacare succeeding in reducing the number of uninsured adults?

The ACA has begun to make good inroads into covering the uninsured. But as the law is structured, we will probably never cover everybody.

Going forward, do you think the law will continue to reduce the number of uninsured adults? Will all Americans one day be covered?

The law prohibits coverage of illegal aliens, a number difficult to pin down but estimates are at least about 12 million. Even for those eligible, an obstacle may be cost. Let’s start with what premiums and out of pocket expenses will be for next year’s exchange offerings. I expect costs to go up for three reasons. First, the exchange population is older than expected. Second, costs for this population has been higher than average, particularly for expensive pharmaceuticals. Third, plans only had a couple months of data to project next year’s expenses. The prudent business decision given these facts is to raise premiums and/or out of pocket expenses. It may still be cheaper to pay a penalty than have insurance.

What do you think are the major obstacles facing Obamacare's implementation in the near term? In the long term?

The one mitigating factor may be federal subsidies. For the first few years, the federal government will subsidize the losses of exchange plans. When those subsidies go away, however, the premiums may rise significantly.

Another problem with coverage may be eligibility. The ACA employer mandate only requires coverage of employees, not families. Many employers are dropping or considering dropping family coverage. The children of these employees have had the CHIP to cover them, but that program is due to sunset without renewal. These problems will not affect all Americans, however.

What do you think is the most common misconception people have about Obamacare?

Since each state has a different template for exchange plans and the costs of care in each state differ considerably, some will find insurance affordable, while others may find it a very bad value. For example, in Illinois, the exchange has some very good deals at all metal levels. In Connecticut, however, I know a family of four on COBRA who found it to have more benefits than any exchange plan and is cheaper than the lowest cost bronze choice.

To what extent is Obamacare succeeding in reducing the number of uninsured adults?

It appears to be having very modest success so far. By my rough calculations it has, at best, reduced the number uninsured in the private market by about 1.8 million to 3.1 million, far short of 6 to 7 million predicted by the CBO and White House. As for Medicaid, there is probably some reduction there as well, but at this point we do not have accurate numbers on that.

Going forward, do you think the law will continue to reduce the number of uninsured adults? Will all Americans one day be covered?

As to the first part of the question, I doubt that it will further reduce the uninsured because Obamacare regulations will drive up the price of insurance on the individual market starting in 2015. As a result, people who are not eligible for subsidies—those making over 400 percent of the federal poverty level—will have more and more incentive to drop out as insurance rises above what they would pay in a freer market. As the number of uninsured above 400 percent FPL rises, it could offset any gains made elsewhere.

As for the second part of the question, the answer is no, since in no system anywhere will everyone ever be 'covered’ in any meaningful sense of the term. I’m fairly confident the response to this among the political left would be to point to nations like the United Kingdom and Canada and claim nearly everyone is covered by those systems. But such systems have waiting lists on which people with serious ailments can wait months or even years for treatment. Some even die before while on the wait list. To call that 'coverage’ requires stretching the definition of the word to point that it is meaningless.

What do you think are the major obstacles facing Obamacare's implementation in the near term? In the long term?

The short-term challenges will be trying to ensure that everyone on the exchange is a legal resident and that everyone who received a subsidy got one that is consistent with their income. A recent Office of the Inspector General report found he immigration status of about 1.2 million exchange enrollees has not yet been verified and the income status of another 960,000 may not be accurate.

Long-term I see two major problems. One that I mentioned above is rising premiums in the individual market. As that happens it will increase the ranks of the uninsured. It may also drive more young and healthy people out of the market, resulting in even higher premium increases and, eventually, a death spiral.

The second is that Obamacare looks to become a serious drag on the federal budget. Some of the revenue sources such as the 1099 tax and the revenues from the CLASS Act have been repealed. It also seems that other taxes, like the Cadillac tax, will never go into effect. Further, some cost-saving methods, like cuts to Medicare Advantage, have been reduced and others like IPAB will probably never be used. More spending, fewer cuts, less revenue—that’s a recipe for deficits.

What do you think is the most common misconception people have about Obamacare?

I think the biggest misconception is that Obamacare will help people who are sick. In general, lower income people have more health problems than those with higher incomes, yet people with lower income are getting some of the worst coverage. If you make less than 100 percent FPL you end up on Medicaid which is probably the worst coverage in this country. Those higher up the income ladder can go on the exchange and get a subsidy, but they are finding plans with skinny networks—few doctors and hospitals. That’s a burden for sicker people as they probably need greater access to doctors and hospitals. Furthermore, people who have a serious illness that needs costly specialty drugs face very high cost-sharing under exchange plans.

The main reason for this is sick people are not a potent political force. Few people get seriously ill each year relative to the total voting population, so they don’t amount to much of a political force on Election Day—assuming they vote at all. Given their condition, they probably aren’t organizing, holding protests, and doing other things that can influence public policy. Any government run health-care system will tend to direct resources to those who have political power. The problem is that those who are in most need of the health-care system, the very ill, have very little political power.

To what extent is Obamacare succeeding in reducing the number of uninsured adults?

It is working - particularly for states that expanded Medicaid where childless adults got coverage for the first time.

Going forward, do you think the law will continue to reduce the number of uninsured adults? Will all Americans one day be covered?

Not as currently designed. Law does not address underlying rising cost of health care and generally subsidizes more costly insurance that could create and even greater moral hazard problem for some segments of the individual market - which will raise premiums even more over time and thus reduce coverage from best case ACA by 2016-7.

What do you think are the major obstacles facing Obamacare's implementation in the near term? In the long term?

Near term and long term: linking back office of exchange and treasure seamlessly with health plans.

Long term: getting states to pay for their own exchanges without federal money.

What do you think is the most common misconception people have about Obamacare?

It is national heath insurance and everyone gets covered. In reality it is a relatively modest change to the private health insurance system focused mostly on the fair small individual and small employer market. However, the Medicaid expansion combined with claw-back of Medicare Advantage payments to finance part of the law will remain politically toxic for several election cycles to come.

To what extent is Obamacare succeeding in reducing the number of uninsured adults?

We do not yet have rigorous research that controls for other influences but my guess is that the number of uninsured adults covered because of Medicaid and exchange subsidies is on the order of 3 to 5 million so far—about 10% of the 47 million starting point uninsured. There has been an increase in people with private employment based insurance that is at least as large and attributable to the recovering economy, not Obamacare.

Going forward, do you think the law will continue to reduce the number of uninsured adults? Will all Americans one day be covered?

The CBO guesses that it will reduce the number of uninsured by somewhat more than half. I think about a 50% reduction is more realistic but that will depend on whether the individual mandate is retained and whether plans offered on exchanges are attractive. Much of the new private coverage will be high cost sharing coverage (bronze or catastrophic) which reduces the headcount of the uninsured, provides them with financial protection against big losses, but does not do much for access to care especially if charity care shrinks. Better than the status quo ante, but still far from universal.

What do you think are the major obstacles facing Obamacare's implementation in the near term? In the long term?

Politics in the short term and the budgetary cost of subsidies to exchanges and Medicaid in the long term. Not sure the taxpayers will be willing to pay the high cost—even though I hope so.

What do you think is the most common misconception people have about Obamacare?

That it is a big deal. It seriously affects less than 10% of the population now; the largest fraction it can affect is below 20%. Of course all the rest of us will have to pay for this minority but our insurance premiums and access to care will not be much affected.

To what extent is Obamacare succeeding in reducing the number of uninsured adults?

Separate data from the Kaiser Family Foundation and the Gallop organization indicate that the number of uninsured people fell after the ACA was implemented. I suspect that it will fall even more over the next few years as people learn more about their options.

Going forward, do you think the law will continue to reduce the number of uninsured adults? Will all Americans one day be covered?

In my opinion, the only way to achieve universal coverage is to pair a strong individual mandate with sufficiently high subsidies to low and moderate income individuals. Without these, there will certainly be a portion of the population that opts to forgo coverage.