What's Next for Obamacare

Monday marks the end of open-enrollment for the Affordable Care Act. Now comes the real test for the law.
Lucy Nicholson/Reuters

Obamacare's first enrollment period is ending—and with it, a half-decade of debating the law solely as a vague political abstraction.

How the Affordable Care Act would play out has been mostly a theoretical question until now; Republicans predicted it would collapse in on itself (didn't happen), while Democrats swore the public would embrace it as time went on (also didn't happen).

The end of the first open-enrollment period provides real-world data to measure the law's progress—and those results will help define the challenges the law faces as it grows out of its infancy.

We won't know for a few more weeks exactly how many people picked a plan during the six-month enrollment window, but it's somewhere north of 6 million. And we won't know until much later—if ever—how many people paid their first premium, or how many enrollees were previously uninsured.

Both of those are critical metrics for evaluating the law's performance. Neither answer, however, is likely to move the law back to the other side of the key threshold it has already crossed: signing up enough people to push ahead into 2015 and 2016.

"The ACA has survived an election and a Supreme Court challenge and a government shutdown and a website debacle, and now doubts about its enrollment totals," said Drew Altman, president of the Kaiser Family Foundation.

With millions of people signing up, the law has cleared one long, difficult set of hurdles and has defied the darkest predictions of its critics. But that doesn't mean it's out of the woods entirely—it's just on to the next long, difficult set of hurdles.

What will happen to premiums?

It's too flip to say the national enrollment data "doesn't matter"—the whole point of the law was to cover millions of uninsured Americans, and whether that's happening matters very much. But the national total doesn't say much about of the law's sustainability or what happens to premiums next year.

Premiums will go up, because premiums go up every year. The size of next year's premium increases depends on enrollment and demographics in each state, and even within specific regions of each state.

Some states are faring better than others: California is well-positioned for 2015, with enrollment above expectations and a competitive market. On the other end of the spectrum are states like Mississippi, where there's only one insurance company in the state's exchange and the population is relatively unhealthy to begin with.

The demographic mix is pretty steady across all 50 states. Nationally, young adults—the most coveted enrollees—made up 25 percent of all sign-ups through the end of February. The percentage will probably improve in the final analysis; young people were always expected to sign up at the last minute.

Generally, if the risk pool in a particular market turns out older and sicker than expected, insurers are more likely to raise their premiums. We don't know precisely what insurers expected—they all priced their plans independently, and the law includes several programs designed to absorb any surprises and keep premiums as steady as possible. In competitive markets, insurers likely will try to keep increases to a minimum, but industry insiders caution that hikes are looking likely, at least in some parts of the country.

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Sam Baker is a health-care correspondent at National Journal.

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