6 Questions That Will Determine Whether Obamacare Is a Success in 2014

If 2013 was the year of anecdotal horror stories, will this be the year it all comes together?
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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.

Meanwhile, a study in Science found that people who previously gained Medicaid coverage went to the emergency room 40 percent more than those who didn’t enroll in the program, even for issues that could have been treated by primary care doctors. That pokes holes in the idea that Medicaid will save money by encouraging low-income individuals not to use ERs for non-emergency care.

4) Will enough healthy people sign up?

In the end, bros may hold the key to Obamacare’s success. The law needs lots of young, healthy people to sign up for health insurance to counterbalance older enrollees and those with chronic conditions. (This is because insurers make make money on healthy people and lose money on sick people. Pre-Obamacare, insurance companies dealt with this by simply refusing to insure the sickest people. The ACA said they must take all comers.)

The problem? Young people don’t seem eager to sign up for insurance. A Harvard Institute of Politics poll from a few months ago showed that 30 percent of 18-29 year olds don’t plan to sign up for coverage, and 40 percent are on the fence.

If insurers can’t reach this balance, the market may tumble into what’s known as a “death spiral”: Insurers raise premiums to make up the losses from all their sick customers, which causes more healthy people to drop out, which causes them to raise rates again, and so on.

Some people are extremely worried about this possibility. But others aren’t, because the federal government has created a bunch of failsafes to help insurance companies through the rocky next few years. And we all keep our fingers crossed that, because the penalty for lacking health insurance gets steeper every year, eventually the bros will listen to their moms and sign up for a plan. And get a haircut while they’re at it.

5) Will the website start working on a reasonable way?

After Healthcare.gov’s abysmal debut, the site began working marginally better over the last few months of 2013. But as the dust settles from the December 24 deadline to get coverage by January 1, it’s clear that not all the bugs have been worked out.

More than 100,000 people who signed up for Medicaid or the Children’s Health Insurance Program weren’t actually enrolled, because of a glitch. There’s still no easy way to update your profile if you’ve had a baby or have experienced some other life-altering event. When I attended a Dallas enrollment event recently, I was told that some enrollees weren’t able to pay for their plans through the site and instead had to call the insurance company directly.

6) What’s to become of the birth control mandate?

The Supreme Court has agreed to hear a case brought by Hobby Lobby, a Christian-owned, Oklahoma-based crafts purveyor and by Conestoga Wood Specialties, a cabinet-making company in Pennsylvania, which object to the law’s requirements that companies cover contraceptive pills on their insurance plans.

Hobby Lobby CEO David Green has said he specifically opposes some of the drugs that would be covered, such as Plan B, which he says prevents human embryos from being implanted in a woman's womb and amounts to abortion.

If the companies win, not only could it impact female employees of other religious organizations, some fear it could be the start of business owners using the religious exemption to opt out of a host of other laws.

"If the court strikes down the contraception mandate, the implications could be broad,” Adam Winkler, a liberal law professor at UCLA, told Talking Points Memo. “It could give businesses the right to seek exemptions from any number of generally applicable laws, including laws protecting against discrimination on the basis of sexual orientation."

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Olga Khazan is an associate editor at The Atlantic, where she covers health.

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