We have now passed several key milestones in the open enrollment cycle for the Affordable Care Act: The deadline to sign up for coverage that was effective in January, the due date to pay for that coverage, and the deadline to enroll in coverage that is effective this month. The latest update from the Obama administration is that more than three million consumers have signed up for coverage on the federal and state insurance exchanges. Unknown is how many have paid for their plans and how many of these enrollees are newly insured (as opposed to people whose coverage was canceled).
Periodically during this open enrollment cycle, we’ve checked in with experts to get past the sound bites so endemic in this heated political debate. This week, I talked to Dr. David Blumenthal, president of the Commonwealth Fund, a New York foundation that conducts health policy research and whose mission is to “promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable.” While the foundation does not endorse legislation, it is generally seen as supportive of Obamacare’s goals.
Blumenthal was previously the national coordinator for Health Information Technology in the Obama administration. He is the brother of U.S. Sen. Richard Blumenthal (D-Connecticut).
The Commonwealth Fund has recently issued reports exploring Americans’ experiences with the health insurance exchanges and how states are implementing the act. The fund has a wealth of data that’s worth exploring. My Q&A with Blumenthal has been edited for length and clarity.
"First, let me say that I think the real success of the law will be judged over five years, not six months. In fact, this president, President Obama, has until January 2017 to establish it as a fixture in the American social policy firmament."
It almost feels like after such a disastrous launch, folks have a bit of Obamacare fatigue. Is that a fair way of putting it?
I think that folks who cover this closely like you and the media, and maybe us in the cognoscenti world, may have a little bit of fatigue, but I think the American public is just learning about this law really. They’re getting past all the superficial characterization and the caricatures and beginning to understand what’s really in the law, whether it makes sense for them to seek coverage, and whether they are eligible for coverage. I actually think the uninsured still have a lot to learn about it, particularly in states where there has been a mass amount of misinformation and a conscious effort to prevent people from learning about the law. In fact, I think we’re not at the point of fatigue. We’re at the beginning of trying to introduce the public to the serious details of this legislation.
Come March 31, what do you need to see to call this period a success?
First, let me say that I think the real success of the law will be judged over five years, not six months. In fact, this president, President Obama, has until January 2017 to establish it as a fixture in the American social policy firmament. I think that we are close to being able to say that the March 31 open enrollment period is already a success. And let me break it down for you. We have 2.2 million people who’ve already selected plans through the exchanges [as of the end of December], which is about 30 percent of what CBO [the Congressional Budget Office] predicted. We have about six million people who have been found eligible to enroll in Medicaid, and we have three million young adults who weren’t previously insured who are now insured under their parents’ policies. ... You’ve got about 11 million people who’ve been touched by the law, maybe as many as 15 million. That’s really quite an astonishing number for the first six months.
If you want to just focus down on the exchanges and enrollment through the exchanges, I would say that if there are five million folks who have chosen plans through the exchanges by the end of March—five million of the seven million that CBO projected—that would be a strong accomplishment for the law and the administration could claim success for the private exchanges. But as I said earlier, I think they are on the verge of being able to claim success for the law as a whole.
There’s a whole other part of the law which you’re aware of which most Americans are unaware of, which has to do with the [health care] delivery system reforms, and they have been moving along at a fairly deliberate pace as well.
You talk about the five million people who may gain coverage in the exchanges, but what about people who had their insurance plans canceled? CBO didn’t anticipate a net change in the number of people insured through the individual insurance market.
There is obviously a number of people, we don’t know exactly how many, who have been told that their policies don’t meet the basic minimum standards set out under the regulations implementing the law. Some of them are now getting new policies through the exchanges and some of them are now having their plan continued at the discretion of state insurance commissioners. There was an unanticipated effect on the currently insured that the administration is trying to juggle. That was obviously not a great success story, but my view of most social legislation and indeed most programs undertaken by government of any kind is that they all have unanticipated effects. They are all born imperfect and they all need to be modified over time. The question is on balance do they do more good than harm and is the administration—whichever administration, the administration that passed the law or the administration that’s managing the law after its passage—nimble and effective in adapting the statute and the regulations to the reality that’s discovered. No legislation is perfect. The most revered programs in our social portfolio—Medicare, Social Security, you name it—have undergone massive changes over time as they experience problems that were either unanticipated or different from what was expected. That should be what happens to this program as well.
What needs to happen for you to call it a failure?
If over the next three to five years, there are not significant reductions in the number of uninsured and underinsured Americans at a cost that the nation can afford, then I think it would have fallen short of expectations.
There’s a lot of rhetoric on both sides and it seems almost shifting predictions too. Are both sides of the debate posturing so that the ends match their political aims?
Sure. My view of the current discussion about the Affordable Care Act, if you can call it a discussion, is that it’s a continuation of the 2012 election and a prelude to the 2016 election with a brief stop along the way for the 2014 midterms. I see this debate as quite fundamental to politics and policy in the United States. It reflects deep-seated, longstanding disagreements about the role of government in general, the role of government in health care, and it would be surprising to me if those debates didn’t continue and if the arguments made on either side didn’t change in order to gain the advantage in advance of those important upcoming electoral challenges. 2016, I think, will be the ultimate and probably final judgment on the law, and the question will be whether a Democrat who supports the law is elected or a Republican who opposes the law is elected. And then if it is someone who opposes the law, whether they decide they want to fix it or try to dismantle it.
From a historical perspective, there are some parallels to what happened in 1968, when Richard Nixon was elected president following the Great Society programs and their enactment, which the Republicans vigorously opposed. Nixon, in a different era with a different Republican party, decided he had to make the law work, and as you know there have been continuous reforms to Medicare under both Republican and Democrat administrations since. But it became clear that too many people depended on it to repeal it or to try in any way to undermine it.
How are state Medicaid programs adapting to the huge influx? We hear a whole lot less about consumers who are receiving coverage in this way but we also hear that it’s hard to keep track of exactly how many have enrolled.
We know that there have been roughly six million Americans found eligible through the exchanges or through other devices for Medicaid in the 26 states that have agreed to expand Medicaid, that’s out of the nine million that CBO projected through 2014 as enrolling in Medicaid. We don’t know how many have actually enrolled but it’s going to be in the many millions. Your question gets at whether that’s a burden that the states are having trouble managing. From what we can tell, the Commonwealth Fund works with state Medicaid directors actively, there’s no concern about managing this influx of new enrollees. There is concern about financing going forward. That is whether the federal government will sustain its commitment. There is also concern about the underlying efficiency of the health care system that serves both Medicaid and non-Medicaid patients.
You recently released a report saying that 63 percent of those who are potentially eligible for the law’s health coverage options are aware of the new marketplaces. Around the same time, the Kaiser Family Foundation released a survey showing that unfavorable views now outnumber favorable views among the uninsured by roughly a two-to-one margin. How do you reconcile the different findings?
I think first of all, the uninsured are becoming aware of the law but I don’t think they yet understand it. I think it’s an extremely difficult law to understand. And I think there are a large number of uninsured in places like Texas and Florida where there has been relentless negative characterization of the law. I was just in Orlando for a meeting and watching a television and up comes an incredibly negative advertisement funded by a group opposed to the Affordable Care Act.
As they become more aware of it, they’ll go through a period where they’re concerned about whether it’s good for them. Now that the website is up and running and can accommodate a surge of new enrollees, the administration has a chance to get a new message out as do the insurance companies that stand to benefit from new enrollees. We’ll see what happens. One thing you might conclude is that it’s not likely to get any worse than it already is from the standpoint of people’s attitude toward it.
Any final thoughts?
One general point I want to make and it’s easy to get lost. The Affordable Care Act was passed to rescue the private insurance market, which was unraveling prior to the enactment of the law. That’s why insurance companies are so supportive of it and that’s why so many people who had lousy insurance policies are now finding that in a new regulated world with consumer protections, they’re finding that their old policies were not sufficient and that they needed to be upgraded. Going back to the world before the Affordable Care Act is not a viable option. That’s the background, that’s the substrate with which we’re dealing right now. We’re in the process of creating a new insurance market for the individuals and the small groups, and that process is going to have bumps, but it was a necessary change to preserve the private insurance market in the United States.