Obamacare: Mission Accomplished?

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When any politician or leader proclaims “mission accomplished,” the statement is typically regarded with no small measure of skepticism. When ushering in a massive new social program or announcing the conclusion a widely-protested military conflict, success is often hard to define and, more importantly, by no means a perfect reality. That phrase has only been further tainted by former President George W. Bush. Addressing sailors aboard the the aircraft carrier USS Abraham Lincoln on May 1, 2003, standing in front of an American-flag emblazoned sign proclaiming “mission accomplished,” Bush stated that the United State’s major combat operations in Iraq were at an end. But in the weeks and years that followed, guerrilla warfare only increased; the vast majority of American civilian and military casualties came after the speech. Since that day, the words “mission accomplished” has been used to ironically indicate a mission that has been anything but fully accomplished.

The words “mission accomplished” have not been expressly used by the Obama administration to describe the success of the Affordable Care Act to date, and for good reason. But the term has been bandied around by the media, and the White House itself has framed the first, six-month enrollment period as triumphant moment for the reform of the American health care system.

To the Obama administration, reaching 7.1 million enrollments meant success; a target hit. As President Barack Obama said in a statement released late on March 31, the last day of the enrollment period, “now, millions of our fellow Americans have the comfort and peace of mind that comes with knowing they’re no longer leaving their health and well-being to chance. For many of them, quality health insurance wasn’t an option until this year — maybe because they couldn’t afford it, or because a pre-existing condition kept them locked out of a discriminatory system.” In his opinion, “regardless of your politics, or your feelings about the Affordable Care Act, millions more Americans with health coverage is something that’s good for our economy and our country.”

But even more importantly, at least for the sake of politics, Obama’s April 1 speech in the Rose Garden was meant as a final rebuttal to the critics of the health care reform intended to be the signature achievement of his presidency. “I’ve said before, I will always work with anyone who is willing to make this law work even better,” he stated. “But the debate over repealing this law is over. The Affordable Care Act is here to stay.”

Commentators — from politicians to comedians — took a different angle.

“This is President Obama’s Mission Accomplished moment,” Republican Senator John Cornyn of Texas told Time magazine. “I think it’s going to come back and bite him later on,” he added. His comments indicated that the critics of the Affordable Care Act are far from finished with the debate. Just as the president was lauding “all benefits that have been taking place for a whole lot of families out there” as a result of the Affordable Care Act, which will improve the lives of “our middle class” and stabilize “our fiscal future,” Republican lawmakers issued a warning of skyrocketing premiums for those policyholders who lost their coverage when insurers cancelled non-Obamacare-compliant health coverage en masse last fall. They also reaffirmed their commitment to repealing and replacing Obamacare on Wednesday, even though more than 7 million Americans have enrollment in health insurance plans via the Affordable Care Act’s online exchanges.

Similarly, House Majority Leader Eric Cantor, a Virginia Republican, made the oft-repeated, “Obamacare is not a success” argument last Wednesday, highlighting the “millions who lost their health care policy that they liked” and “those families who want to see the doctors they want to see, not what Washington wants them to see.”

Jimmy Fallon — host of NBC’s “Tonight Show” — noted that hitting a targeted enrollment number was also not much of a success. “That’s right, the White House said that it surpassed its goal for people enrolled in ObamaCare. It’s amazing what you can achieve when you make something mandatory and fine people if they don’t do it. And then keep extending the deadline for months. It’s like a Cinderella story. It’s just a beautiful thing,” he said during a March 31 standup routine. “You make everyone do it. Isn’t it great how many people do it? But if you still haven’t enrolled, you might have to pay a penalty called the individual shared responsibility payment, which is 1% of your salary. Then Americans said, ‘Man, good thing I don’t have a job.”

The problem is that determining the success of the reform cannot be distilled into sound bites. It is hard to argue against an achievement that results in a massive decrease of the uninsured population of the United States. And, data compiled by the research firm Gallup has shown that the uninsured rate has fallen to the lowest level recorded since 2008, dropping 1.5 percentage points to 15.6 percent in the first three months of this year. That decline in the insured rate was spread across every major demographic group. It should be noted that since the research firm first began tracking insurance coverage in 2008, when the uninsured rate was at a low of 14.5 percent, annual readings have increased every year except for in 2012.

Uninsured

Gallup’s measure represents the first quarterly period in which mandated individual health-care insurance was in effect. “This quarterly figure represents the average percentage of adults without health insurance since provisions requiring Americans to have insurance established by the Affordable Care Act went into effect on Jan. 1 of this year,” noted Gallup’s Jenna Levy. Plus, “the current figure as of today is likely lower given that uninsured rates declined throughout the quarter, including in late March.” While Gallup noted both the relationship between the Obamacare exchanges’ enrollment period and the decline of the uninsured rate, as well as the numbers of Americans who obtained coverage either through the exchanges or the expansion of Medicaid, the report did not specifically attribute the gains in insurance coverage to the reform. What Levy did write was that drop in the uninsured rate was “a sign that the Affordable Care Act, commonly referred to as ‘Obamacare,’ appears to be accomplishing its goal of increasing the percentage of Americans with health insurance coverage.”

However, the key words in that assessment is “appears.” According to Gallup’s data, it appears that the uninsured population declined by a notable percentage. Based on U.S. Census Bureau data, the estimated size of the country’s adult population last year is 242 million, meaning the what the firm’s data is extrapolated, the decline in the uninsured population represents more than 3 million people. While this appears to be evidence of the effectiveness the health care reform, it is important to remember that Gallup conducted just 43,500 interviews and causality was not take into account.

But because the Affordable Care Act was such a disruptive force in the American health care system, any measurement of success cannot end with an overview of the uninsured rate. Equally important is the functioning of the cornerstone provision of the health care reform, the online insurance marketplaces known as exchanges. So far, the administration’s numbers hold few clues about who the 7.1 million enrollees are and, more importantly, how many of them were previously uninsured. And, as President Obama’s own press secretary, Jay Carney said back in January, who those Americans who signed up for the exchange are very important for the success of the system and the reform as a whole.

“Well, I think success looks like having many millions of people sign up. What is important–because I think the conflation here is an estimate, one of which, by CBO, was 7 million, of a total number of enrollees and what that means. Obviously, the more enrollees there are, that’s a measure of success,” he said in January 6 press briefing, when the White House was still recovering for the botched rollout of the insurance exchanges. “But in terms of how effective the marketplaces function, the makeup, the mix of the population that enrolls is more important than the total number. And that’s why so many efforts are under way to reach different populations with the message of the options available to people for quality, affordable health insurance.” What Carney is suggesting is that straight numbers are far less important than the mix of enrolless — young and healthy versus old and sick as well as previously insured verses long-time uninsured.

The exchanges, along with the expansion of Medicaid, were designed to make affordable health insurance accessible to most all Americans. In the states that chose to expand health care assistance program, it appears that the numbers of uninsured decreased measurable. The Los Angeles Times reported last week that the data from the Rand Corporation shows that 4.5 million previously uninsured adults have enrolled in state Medicaid programs — and data compiled by the consulting firm Avalere Health reflected a similar reality. But unpublished data from the Rand Corporation — obtained by the Los Angeles Times — suggests that the exchanges were not effective in significantly decreasing the uninsured, who numbered 48 million in 2012. Numbers from the Rand Corporation study indicate that bare 858,000 previously uninsured Americans have paid for new policies purchased through the exchanges.

That statistic means that the remainder of the individuals who have paid for exchange policies — a figure also unknown as the administration has confirmed that all 7.1 million enrollees have not paid the first month’s insurance premium to guarantee coverage — are individuals who lost coverage last fall when insurers cancelled non-compliant policies. Of course a number of holders of policies that were originally cancelled by insurers were able to renew those policies after a wave of backlashed forced President Barack Obama to implement an extension. But that extension, which was subject to the approval of each state’s insurance commissioner, was only allowed in about half of all states.

While the drop recorded by Gallup’s uninsured index is a positive sign, it will be quite some time before the true extent of the Affordable Care Act’s impact on uninsured Americans will be fully understood.

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