When the Affordable Care Act became law, nearly four years ago, it was easy to imagine that the political debate would basically end on January 1, 2014. The law would be taking full effect, with millions finally getting insurance either through Medicaid or subsidized private insurance. There would still be talk of how to fix the law’s flaws and how to fine-tune its strengths. But the debate over whether Obamacare was a fundamentally sound concept would be over.
Now that assumption seems hopelessly naïve. Yes, the Affordable Care Act is settled law. The Supreme Court and the electorate saw to that in 2012. Even most Republicans acknowledge they cannot dislodge the program, although conservatives continue to stir passions—and donations—by vowing to pursue total repeal. But the debate over the law’s merits will continue, at least through the midterm elections and perhaps beyond.
And the debate will probably look a lot like it has for the past few months, with proponents and critics arguing not just about priorities but also basic facts. How many people are getting insurance? Who’s paying more for coverage and who’s paying less? Is access better or worse? Are costs going up or down? The arguments, however familiar and tedious, aren’t going away.
But if we’re destined to keep having these same fights over and over again, maybe can learn to have them more intelligently. With that in mind, here are five rules for thinking about Obamacare and its impact. It’s based loosely on a speech I gave a few months ago, at the University of Michigan, during a conference on Obamacare and journalism. (You can watch it here.) I had addressed my presentation to the media, but the rules below should apply to everybody talking and thinking about health care in the months and years to come.
Rule #1: Don't ignore the obvious.
When the stories about higher premiums and plan cancellations first began appearing in October, my first reaction was “This is news?” People who follow health policy understood, from the beginning, that reform had to reorganize the market for people buying on their own—and that, as a result, some small portion of Americans would not be able to buy the same policies for the same prices. Many of us first wrote about this in 2009, when the Congressional Budget Office made its first official estimate of how health legislation would affect premiums for people with private insurance. Earlier this year, blogs were full of arguments over exactly how many people would feel this impact. When the NBC News “investigations” unit reported this as a major scoop, I noted with a little snark that the article’s source was a set of regulations published years before in the Federal Register—in other words, hardly the stuff of Woodward and Bernstein.
But rate increases and plan cancellations were news anyway. And journalists like me were wrong not to recognize that. Health care experts may understand the law, with all of its trade-offs, but that doesn’t mean the public does. Most Americans don’t read policy blogs—not because they’re dumb or indifferent, but because they’re busy and have better ways to spend their time. For that matter, most Americans don’t even understand the basics of health insurance.
Informing the public about the basic provisions of Obamacare may not seem exciting to those of us who have been writing about this law for the last few years. But with Obamacare’s coverage provisions finally taking full effect, basic education may be the most important job the media does.
Rule #2: Pay attention to scale.
There’s nothing wrong with personal anecdotes. They make abstract issues seem real. And they convey nuance that statistics cannot. But anecdotes matter a lot more when they tell us about broader trends. And we can’t know that without having some sense of scale.
That’s obviously true when it comes to stories about the non-group market. As a percentage of the population, the number of people who get coverage on their own (rather than through employers or government programs) is pretty tiny. It’s less than 5 percent. Of those people, only a fraction of those people stay in the non-group market for more than a year or two. And among that subset, only a fraction have decent insurance or won’t be eligible for subsidies in the new exchanges.
Of course, this is a big country: A tiny fraction of the population can still amount to tens of thousands, hundreds of thousands, or even a million people. And even small numbers of people matter. But when weighing the costs of Obamacare, we should start with a realistic sense of how many people are really affected—and what’s actually happening to them.
This week will provide a good test. Americans who enrolled in coverage by December 24 should have coverage that’s ready to go on January 1. But, as Timothy Martin and Christopher Weaver of the Wall Street Journalreported on Tuesday, insurers are rushing to finalize arrangements—and almost surely won’t get to everybody. Meanwhile, “back-end” problems in the insurance exchanges mean some applications got to insurers with bad data. Inevitably some people are going to show up at pharmacies, physician offices, and hospitals in early January—only to discover their insurance isn’t working yet. These stories will get a ton of attention. But how many people are actually having trouble getting care—and what’s actually happening to them? Are they missing out on medications, for example, or are pharmacies extending them limited supplies until insurers can finalize enrollments? (The Administration has been working with pharmacies to allow this.) Those are the essential questions.
Rule #3: Accept ambiguity.
The Obama Administration on Sunday released enrollment numbers for private plans on the Affordable Care Act exchanges. But that number didn’t tell us a lot of things. We don’t know what kind of insurance these people had before—or whether they had insurance at all. In fact, as Sarah Kliff noted recently at the Washington Post, even the enrollment numbers themselves are pretty sketchy—subject to imperfect reporting and inconsistent definitions from the states.
And we won’t have more reliable information for a while. Our knowledge of insurance coverage comes primarily from surveys and studies—some by private organizations like Gallup, and some from government agencies like the Census. Our knowledge of what people are paying for medical care and what kind of care they get? That comes primarily from studies that take months, if not years. We can make some pretty good guesses, based on what’s happened in the past. But we rarely know as much as we’d like to think.
Rule #4: Acknowledge complexity and trade-offs.
The Affordable Care Act’s critics say premiums for people buying coverage on their own will actually increase. That’s true. The law’s defenders say tax credits offset the cost for many and probably most of those people. That’s also true. The law’s critics say some people will lose coverage from employers and won’t be happy about it. That’s true. The law’s defenders say most of those people will be better off, because they’ll be low-wage earners getting subsidies on the exchanges or they’ll be older workers who had stayed working because, previously, it was their only way to get benefits. That’s also true.
You may notice a theme here. Obamacare sets in motion all kinds of changes. They will typically affect different people in different ways—creating winners, losers, and all sorts of people in between. Are there more winners than losers? How much worse off are the losers? Those are the kinds of questions we need to answer if we want to make a judgment about the law. And the answers are rarely simple.
Rule #5: Consider the real counter-factual.
Health insurance premiums are going to rise next year. And lots of people are going to blame Obamacare. But insurance premiums rise every year. The real question—not just next year, but in the years to come—is whether they rise more quickly or more slowly than they would have if Obamacare had never become law.
And that’s true of other developments, as well. Before the Affordable Care Act took effect, employer-sponsored insurance was deteriorating and the number of people without coverage was rising. Employers and insurers were looking for new ways to cut costs—which in some cases meant asking beneficiaries to shoulder higher out-of-pocket costs or limiting them to smaller networks of doctors and hospitals. Obamacare won’t stop these trends. The question is whether it slows them down or somehow makes them less punishing to consumers.
Sam Baker of National Journal had a great piece on this a few weeks ago:
The healthy are subsidizing the sick. Insurance companies are tightening access to doctors. Plans with low premiums have high deductibles. Sometimes it rains, Nickelback is still a band, and people continue to die literally every day.
But just because something is happening and Obamacare exists doesn't mean it's happening because Obamacare exists—even in health care.
This is probably the most important rule of all. It will be tempting to judge Obamacare by comparing it to the status quo. But the status quo was changing already. Preserving it was simply not an option. If we want to make a judgment about Obamacare, we have to consider the changes that would have taken place in the law’s absence—and then decide which would have been better. It’s a more difficult standard, because nobody knows what the future would have been like. But it’s also a more honest standard.