An Obamacare open-Enrollment post-mortem

Newspaper articles were written about the success and/or failure of Obamacare scarcely after the law was passed. The US House of Representatives’ 50 or so attempts to repeal or gut the Affordable Care Act (ACA) occurred before the open enrollment period for insurance even ended, before the central piece of the law kicked off proper. Now, as the deadline for signing up for insurance has passed, an evaluation on the Obama Administration’s rollout of the law has begun.

But what does this analysis even mean in the light of the state by state variations in implementation? With twenty-four states rejecting the expansion of Medicaid and thirty-four refusing to create their own exchanges, major aspects in the design of the law are broken through no fault of the administration.

The hope was to cover almost all insured by offering the poor broader Medicaid care and expanding the pool of those eligible, while providing assistance to those slightly wealthier who had avoided purchasing assistance. As a result of refusing expansions of Medicaid, funded primarily through the federal government at minor cost to states, those that have rejected the expansion have created a new donut hole for those too wealthy for their state’s Medicaid service but too poor for a monthly insurance premium.

The area where the Obama Administration arguably did screw up is in the rollout of Healthcare.gov, but even there, with admittedly some mismanagement when building the site, it was not the plan for the Executive branch to build a site for the population it ended up having to handle. The federal exchange was designed to be a backup, but instead, it had to coordinate with HMO’s and insurance companies in far more states than planned. The challenge of building a system which can communicate with the databases of these thirty-four states’ various health coverage programs is massive, especially during the first few weeks when everyone is trying to sign up. By the original design, each state would have the opportunity to tailor its site to the needs of its population. Far from a federal overreach, it was a federalist approach to health reform.

None of this is to excuse the ACA from its very real flaws. The law does far too little to control for rising costs, it filters more money into the inefficient private market with its far higher administrative overhead, and it does very little to address the environmental and societal causes of poor health outcomes. The Obama Administration committed a major mistake in telling people that “If you like your plan, you can keep your plan,” even if most of the plans canceled offered very little in the way of healthcare.

This is instead a criticism of those who act as though the faults of the law rest entirely in the hands of the Obama Administration. With the major part of the law only coming into effect now, it will be impossible to offer a full critique of the ACA until we see how it works out for those who bought insurance in the marketplaces. I suspect, though I cannot know, we will see that those states that actively sought to sabotage the law will have worse health results over time, will see their emergency intensive care costs rise, and overall will have lower enrollment numbers over the years.

These problems are not the result of a poorly designed law. If the law has a flaw with respect to these issues, it is the naïve assumption that states would rather provide their citizens with better healthcare at very low cost to themselves than reject aid for political reasons. The dark lining to all this is that at least we will get to see a controlled trial for the law. The states that bought into Obamacare will compete with those that did not, and we will see who, in the end, made the right choice.

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