The Precarious Success of Obamacare

The Affordable Care Act has drastically cut the rate of uninsured Americans by a third–16 million people–according to numbers released Monday.

The number of uninsured Americans has dropped by 16.4 million since the implementation of the Affordable Care Act, according to numbers released Monday. From the time that open enrollment began in October 2013 to present, the rate of uninsured Americans decreased by 35 percent. That is the biggest improvement in 40 years.

"I think there's a lot to be done in terms of affordability in the delivery system, delivering better quality at a better price," said Secretary of Health and Human Services Sylvia Mathews Burwell, sitting with a small group of reporters at Google's offices in Washington, D.C., this morning. "That's a place where we can and should make a good amount of progress." But the remainder of her report was one of unprecedented success.

Minorities and young adults have seen the biggest gains in access to healthcare. The number of newly insured people includes 2.3 million who gained insurance when the law expanded coverage to those under 26, and 14.1 million from Medicaid expansion, increased insurance through employers, and individuals purchasing through exchanges.

Falling Uninsured Rate

The timing of the announcement, thinly pegged to the fifth anniversary of the bill's passage, is strategic in that the Supreme Court case King v. Burwell stands to undo the progress Burwell described today.

"We think we will win the case," said a senior administration official this morning. If the Supreme Court decides against the federal government, it will be making a decision that tax credits and subsidies will not be available in the 36 states with a federal marketplace. Eighty-seven percent of the 8.4 million people who have come through the federal marketplace are receiving subsidies, at an average of $263 per individual per month.

"When you do the math, for most people, that's a lot of money," said the official. "The relationship between that drop and the affordability that's created through the tax credits or subsidies, one assumes, is extremely real."

Without subsidies, prices of insurance will rise because only sicker people will buy in. As premiums in the individual market go up, a so-called "death spiral" will ensue. While that might sound like a good thing, officials emphasize that it's not. It remains unclear exactly how many people would lose their insurance, but the same senior official today confirmed that the effect would be "massive damage."

Despite demonstrable evidence that the Affordable Care Act is helping to address America's relative squalor compared to other wealthy countries in terms of citizen access to healthcare, few hearts and minds have been won. As of September, only 37 percent of Americans approved of the law (even though 75 percent of newly-insured people like their plan). House Republicans have voted to repeal or gut the law more than 50 times, often rallying around nebulous evils in a malaise of anti-big-government sentiment.

"This is a market system," said a senior administration official, preemptively addressing concerns to the contrary. "Having a successful open enrollment builds the success of the private sector and a strong market."

Burwell and President Obama have lately taken to underscoring their success by telling compelling individual stories. A tearful 27-year-old Anne Ha of Philadelphia sat to her left at a press conference in October and explained how despite eating well and exercising regularly, she started developing chest pain and indigestion. She couldn't sleep for three days. At the urging of her mother, she signed up for health insurance on the federal exchange website. Two weeks later she ended up in the emergency room with internal bleeding, and an endoscopy found stomach cancer. She had half of her stomach removed. "If my mom didn't push me to sign up, I would be faced with bills up to half a million dollars," she said at the time. With her premium included she ended up paying $5,000.

In fact, at every event where Burwell went during open enrollment, a consumer spoke with her from the podium. Last Monday she highlighted a woman who started an empanada business with her family. She is one who now has coverage, because she was working the 2,000-pound meat grinder, nearly caught her hand, and thought, "What am I doing without healthcare coverage?"

"If you have other ideas in terms of people and stories, we're continuing to try to work and do that," said a senior administration official, yielding to the purview of journalists. "My goal every day is to drive this conversation to one of substance. Let's have the conversation about what the trade-offs are. Do you or do you not want pre-existing conditions to be something that can keep you out of healthcare? Do you want people under 26 to have insurance? That's the conversation."

"It is hard, and it is frustrating," said the official, "but what I firmly believe is that if the American people have the right information, they make good choices." The most contentious statement of the day.