It was the most “glorious” of times, it was the most “disastrous” of times. It was the age of cancellation notices, it was the age of lower-than-expected premiums. It was the epoch of skimpy provider networks, it was the epoch of free birth control for all.
The Affordable Care Act is either the best or most evil thing to happen to humanity, depending who you ask (and how much their premium went up). 2013 was marked by the sputtering launch of Healthcare.gov and the start of the law’s nervous implementation. But this year we should begin to see if, and how well, the law is working toward its goal of providing access to healthcare for all. Here are some of the key questions that will determine if Obamacare is seen as a horror or a boon — or something in between.
1) Does health insurance become more affordable for most?
Are most people able to get affordable insurance? This is the most basic question, but also the one that incites middle-class people to grab their pitchforks and write to journalists when the answer is "no."
Obamacare ended health insurance price discrimination based on health conditions and offers subsidies to low- and middle-income people to buy health insurance. However, there are signs that people are finding much higher prices on the individual market. And employer-sponsored insurance also seems to be getting more expensive (but it gets pricier every year, anyway.)
This is, in a way, part of the law’s design:
“Put bluntly, the Affordable Care Act's changes are raising insurance premiums for some people who did well under the old system and lowering them for many of the people who were locked out or discriminated against,” as Sarah Kliff wrote.
The question is, will there be more jubilant stories of the previously-locked-out-gaining-coverage than sob stories of the now-paying-more-for-insurance?
This will be an especially important issue for the thousands of people who received cancellation notices in the autumn because their existing plans did not meet the requirements of the law. The Obama administration offered a last-minute reprieve, saying those affected could stay on their plans, but that grace period ends in October 2014.
“Still, there are bound to be enough people who previously had something better,” as Garance Franke-Ruta wrote, “that concerns and objections will continue into the new year.”
2) Will people be able to see the doctors they want, when they want?
Even as millions of people gain insurance, they may have trouble getting a doctors’ appointment — especially for a primary-care doctor. The Association of American Medical Colleges predicts the country will be 91,500 physicians short by 2020. There’s also evidence that some of the plans on the new exchanges have narrow networks that exclude popular regional hospitals.
For a bad-case scenario, look no further than Massachusetts, which enacted universal healthcare seven years ago. Now, only half of its primary care doctors accept new patients.
Part of the solution lies not with Obamacare, but with Congress: Medical organizations are urging lawmakers to raise the cap on residencies so that more doctors can be trained.
3) How will Medicaid expansion impact the poor?
Though more than 2 million Americans have enrolled in private health plans since October 1, far more — roughly 4 million — signed up for Medicaid, the health insurance program for the poor that was greatly expanded under Obamacare, with the federal government picking up much of the tab.
But only half the states are expanding Medicaid, raising the possibility that a less-robust healthcare safety net in the states that refused could lead to lasting health disparities. Meanwhile, states that are doing the expansion worry about the cost — they’ll have to start paying for 10 percent of the bill for the new enrollees starting in 2020 — and about access issues — more than a third of doctors say they won’t see Medicaid patients.
The law boosted reimbursements for primary care doctors who do take Medicaid, but the raise only lasts for two years.