Boston University health economist Austin Frakt, who blogs at The Incidental Economist (a must-read), said he breaks down winners and losers into short-term, mid-term and long term.
“Short term there are no winners,” Frakt wrote, mostly because of the problems with the rollout. Even if the website issues are fixed by the end of this month, as promised, it will still be hard to get consumers signed up by Dec. 15 for coverage that begins on the first of the new year.
Looking ahead, Frakt wrote:
Medium term (next year, more or less): Providers and would-be Medicaid beneficiaries in non-expansion states are losers. Winners are those who finally get coverage (let’s assume the exchanges function by or soon after the new year). Entities that had to scramble and make sub-optimal decisions due to late-functioning exchanges lose. Same for people who were impatient and jumped at bad deals.
Still, this will be an uncertain, transition period. There may be insurers that opt not to re-enter the market next year. There may be exchanges that look unstable. I would expect some will be near failure, if not fail. All the obvious entities in those states will be losers, unless something can be done.
Big winners are researchers and those who might consume their work. We will learn a lot about exchanges. This is good for the future of health policy.
Long term (well beyond next year): I expect more states to expand Medicaid, bringing the obvious winners. I expect most exchanges to function, and that’s a big win for residents of those states. I expect Congress to continue to not be able to sensibly deal with failing exchanges and other glitches in the law, so there will be losers.
On the whole, I think the law will prove to be successful, and I consider that a win for America. If only we could make sensible mid-course corrections we’d all be winners.
Cost control will remain an issue. If we don’t make progress there, we’ll all be losers in the very long term. But we may have a decade before that really binds.
Dr. Scott Gottlieb, a resident fellow at the American Enterprise Institute and former FDA official, suggested many of the same winners and losers as I identified above.
Other winners include older, sicker patients who do not have employer-provided health insurance, as well as lower-income younger families who earn between $40,000 and $60,000 a year, because they will qualify for subsidies that will lower their costs.
Among the losers: Those who are young and healthy, who will pay more for coverage than they did before. Families who earn more than $60,000 face high premiums even with subsidies. “Also upper income healthy people lose big. They’re forced to buy a pricier policy than they probably want or need with no benefit of subsidies.”
The biggest losers (I agree) are those who earn less than the federal poverty level and who live in states that did not expand their Medicaid programs. When the Affordable Care Act passed in 2010, Congress envisioned that every state would expand Medicaid and it did not set aside money to provide premium subsidies for those patients in the health insurance exchanges. So they will neither receive Medicaid nor help paying their premiums.