How's Obamacare doing in getting people covered?

With the Affordable Care Act (ACA), also known as Obamacare, in the midst of its third annual open enrollment period (Nov. 1, 2015, through Jan. 31, 2016), it's a good time to assess how well the law is doing in getting more people insured.

There are far fewer uninsured. The U.S. Census Bureau, the definitive source of data on Americans with and without health insurance, recently confirmed that, largely because of the ACA, the U.S. uninsured rate has dropped to historically low levels. “The percentage of people without health insurance coverage for the entire 2014 calendar year was 10.4 percent, down from 13.3 percent in 2013,” the bureau wrote in a Sept. 16 press release. “The number of people without health insurance declined to 33.0 million from 41.8 million over the period.”

Yet the Census Bureau also reported great variation in the uninsured rate by state, writing in 1 of its full reports, “Health Insurance Coverage in the United States: 2014,” that “During 2014, the state with the lowest percentage of people without health insurance at the time of the interview was Massachusetts (3.3 percent), while the highest uninsured rate was for Texas (19.1 percent). Six states (Massachusetts, Vermont, Hawaii, Minnesota, Iowa, and Connecticut) and the District of Columbia had an uninsured rate of about 7.0 percent or less.” Whether a state expanded Medicaid to persons with incomes up to 138% of the federal poverty level was the single biggest factor in explaining such variation: “In states that expanded Medicaid eligibility (‘expansion states'), the uninsured rate in 2014 was 9.8 percent, compared with 13.5 percent in states that did not expand Medicaid eligibility (‘non-expansion states').”

Most enrollees like their coverage. Faced with data showing that the ACA is getting more people covered, Obamacare's critics have turned to arguing that enrollees are stuck with low-quality plans. The Hill reported that Sen. John Barrasso (R-WY), a surgeon and a member of the GOP leadership team, told his colleagues on the Senate floor that “there is a difference between coverage and care. ... It's a fact that there are people who now have coverage, and can't have access to care” because of the narrow networks offered by some marketplace plans.

Yet a Kaiser Family Foundation survey released in May 2015 of people who have actually enrolled in an ACA marketplace plan tells a very different story: They like their coverage. Eighty-five percent of them are “somewhat or very satisfied” with their choice of primary care physicians, 75% with their choice of hospital, 73% with their doctor visit co-pays, 70% with their prescription co-pays, 65% with their monthly premiums, 64% with choice of specialists, and 60% with their annual deductible.

It may be getting harder to sign people up. Just as past performance is not a guarantee of future returns when buying stocks, the ACA's track record in getting people covered during the past 2 enrollment periods does not guarantee comparable gains in the future. Because many of the remaining eligible uninsured could have signed up over the past 2 years yet decided not to, they may be more resistant to pleas to sign up now. Health and Human Services Secretary Sylvia Mathews Burwell acknowledged this in a recent speech:

“Those who are still uninsured are going to be a bigger challenge. ... Based on our most recent analysis, about 10.5 million uninsured Americans are eligible for the Marketplace today. Our research tells us that they will be harder to reach. The uninsured are younger. ... Many come from underserved communities. ... And while we will work across the country, we know for example that all these groups are key components in our top five targeted areas: Dallas, Houston, Northern New Jersey, Chicago, and Miami. We've found that costs are still a big concern—about half of the people who are uninsured have less than $100 in savings. And people are worried about fitting premiums into their budgets. Almost 60% of people who are uninsured are either confused about how the tax credits work or don't know that they are available.”

The statement “costs are still a big concern” is backed up by a September Commonwealth Fund survey of people who started last year's enrollment process and then decided not to purchase a plan. “Affordability was a key reason people did not enroll in plans. More than half (57%) of adults who visited the marketplaces but did not enroll said they could not find a plan they could afford. ... the majority of those who did not enroll because they couldn't find affordable plans had lower incomes,” the survey report said.

Many of these low-income non-enrollees may be unaware that the ACA provides cost-sharing subsidies for people with incomes at or below 250% of the federal poverty level. “One startling finding [of the Commonwealth Fund survey] is the fact that among those adults who said they did not enroll because they could not find an affordable plan and did not enroll through a different source, more than half (54%) had incomes that made them eligible for subsidies. It is unclear whether the subsidies are insufficient across income levels to help all those eligible enroll or whether there is a lack of clear information,” the report concluded.

The impact of Obamacare is no longer a cause for speculation. We now know that it has been hugely successful in reducing the numbers of Americans who are uninsured and that most who have signed up like their coverage. We also know that continued state resistance to expanding Medicaid, the concerns of many of the remaining uninsured about plan affordability, and the difficulty in providing the uninsured with clear information about their eligibility for subsidies remain the biggest challenges to getting these individuals covered.