Obamacare reached age 5 on Monday [1]. As I’ve pointed out earlier, this anemic child is not exactly a picture of health, falling behind the lofty expectations set for it on many dimensions. But the one bright spot for its proud parents relates to how much the law has reduced the number of uninsured. The president’s Council of Economic Advisors ecstatically announced last December: “the drop in the nation’s uninsured rate so far this year is the largest over any period since the early 1970s.” A little perspective is in order.

First, taking the CEA’s figures at face value (which my chart below does), this decline amounts to a 2.8 percentage point net reduction in the rate of being uninsured, that is, above and beyond the decline that would have occurred anyway according to CBO [2]. It may well be the biggest one-year decline since the 1970′s, but CBO’s expectation at the time the law was passed was that uninsured risk would drop by 6 percentage points in 2014 alone. Even as late as May 2013, CBO was expecting the net decline to be 3.5%. In short, in its first year, Obamacare scored 46% if we use CBO’s original projection as the scoring standard and 79% if we used the May 2013 projection. Clearly we would like this child to perform better than that in future years. But that would require the number of newly covered Americans to increase an additional 79% this year compared to last year.

Reality check: that is certainly not going to happen. Charles Gaba at ACASignups estimates that estimated paid sign-ups on the Exchanges are only 10.5 million so far, compared to 7.06 million last April [the original post stated 10 million, see Update #1 for explanation]. That’s only a 49% increase, suggesting Obamacare will fall even further behind CBO expectations for 2015 [the original post stated 42%, see Update #1 for explanation]. Medicaid won’t fill the gap, since Medicaid evidently is growing by about 300,000 persons per month. Even if we assume all of these are uninsured, that would reduce the uninsured rate by only 0.1% monthly, or 1.2% over 2015 as a whole. That provides only about half of what’s needed to keep pace with CBO projections, leaving the Exchanges to fill the gap. But as we’ve seen, the Exchanges are lagging behind.

The landmark 2006 Massachusetts health-care law that inspired the federal overhaul didn’t lead to a reduction in unnecessary and costly hospitalizations, and it didn’t make the health-care system more fair for minority groups, according to a new study that may hold warnings for the Affordable Care Act.

Massachusetts’ uninsured rate was cut by half to 6 percent in the years immediately following the health-care law signed by then-Gov. Mitt Romney. Blacks and Hispanics, who have a harder time accessing necessary medical care, experienced the largest gains in insurance coverage under the Massachusetts law, though they still were more likely to be uninsured than whites.

The new study, published in the BMJ policy journal, examined the rates of hospitalizations for 12 medical conditions that health-care researchers say wouldn’t normally require hospitalization if a patient has good access to primary care. These include hospitalizations for minor conditions like a urinary tract infection, or chronic conditions that would require repeat primary care visits over the course of a year.

“It’s thought to be a good measure and one of the few objective ways of looking at access [to health-care provider] in the community,” said Danny McCormick of Harvard Medical School, the study’s lead author.

About 14 million Americans have gained health coverage since Obamacare’s insurance expansion began in 2014 — but those new enrollees haven’t swamped the nation’s doctors’ offices, new research shows.

When the health-care law started, there was concern that an influx of new patients could overwhelm doctors. It’s already hard enough to get an appointment with a primary care provider — wouldn’t millions of newly insured Americans just exacerbate the problem?

New data from 16,000 providers across the country, pulled by the medical records firm AthenaHealth, shows that requests for new appointments just barely edged upward in 2014. The proportion of new patient visits to primary care doctors increased from 22.6 percent in 2013 to 22.9 percent in 2014.

Coping with ever-increasing medical bills is frustrating — and getting more so..

A recent survey by private health insurance exchange EHealth highlights the pressure Americans are feeling. It found that more than 6 in 10 people say they’re more worried about the financial effect of expensive medical emergencies and paying for healthcare than about funding retirement or covering their kids’ education.

People who get health insurance through work and on their own have seen their costs rise dramatically over the last decade.

According to the Commonwealth Fund, a New York think tank, annual increases in work-based health plan premiums rose three times faster than wages from 2003 to 2013. Out-of-pocket costs have also been climbing.

“More people have deductibles than ever before,” says Sara Collins, a Commonwealth Fund vice president. From 2003 to 2013, the size of deductibles has grown nearly 150%.

Whether a person is coping with a severe illness or trying to deal with everyday medical costs, the challenges are many.

Can government get people to buy a product that millions think isn’t worth the price?

That’s the question that health care analysts are asking as they pore over the results of the Obamacare open season that concluded on February 15.

On the surface, the data released earlier this month by the Department of Health and Human Services are encouraging. Nearly 11.7 million people selected a plan this year, compared with just more than 8 million during the 2014 open season.

There are some cautionary signs. Despite the influx of new subscribers, the age profile continues to skew older. Nearly half are 45 or older and 26 percent are over 55. Interest among the young remains largely unchanged over last year.

So is interest among middle income people who lack coverage. Enrollment has been dominated by those with the lowest incomes. HHS reports that 83 percent of people who have selected plans have incomes between 100 percent ($11,770) and 250 percent ($29,425) of the federal poverty level (FPL). Medicaid, meanwhile, has grown by nearly 20 percent since Obamacare was launched, swelling its ranks to 70 million. Roughly 22 percent of the U.S. population is now on Medicaid, despite the refusal of 22 states to expand their programs.

(Reuters) – Arizona Republican Governor Doug Ducey signed a law on Monday that requires doctors to tell women that drug-induced abortions can be reversed and that blocks the purchase of insurance on the Obamacare health exchange that includes abortion coverage.

The requirement that patients be told that the effects of abortion pills may be undone by using high doses of a hormone was the most hotly contested provision during legislative debate.

Supporters said there was ample evidence the reversal was possible if acted upon quickly, although they provided no peer-reviewed studies in support of their position.

Two reports released in the past week demonstrate a potential bifurcation in state insurance exchanges: The insurance marketplaces appear to be attracting a disproportionate share of low-income individuals who qualify for generous federal subsidies, while middle- and higher-income filers have generally eschewed the exchanges.

On Wednesday, the consulting firm Avalere Health released an analysis of exchange enrollment. As of the end of the 2015 open-enrollment season, Avalere found the exchanges had enrolled 76% of eligible individuals with incomes between 100% and 150% of the federal poverty level—between $24,250 and $36,375 for a family of four. But for all income categories above 150% of poverty, exchanges have enrolled fewer than half of eligible individuals—and those percentages decline further as income rises. For instance, only 16% of individuals with incomes between three and four times poverty have enrolled in exchanges, and among those with incomes above four times poverty—who aren’t eligible for insurance subsidies—only 2% signed up.

The Avalere results closely mirror other data analyzed by the Government Accountability Office in a study released last Monday. GAO noted that three prior surveys covering 2014 enrollment—from Gallup, the Commonwealth Fund, and the Urban Institute—found statistically insignificant differences in the uninsured rate among those with incomes above four times poverty, a group that doesn’t qualify for the new insurance subsidies.

Kevin Pace is a jazz musician who teaches music appreciation in Northern Virginia. When the IRS announced it would impose the Affordable Care Act’s employer mandate here in the Old Dominion, Pace’s employer cut hours for part-time professors in order to avoid steep penalties. Pace lost $8,000 in income. That would be bad enough if the penalties the IRS is now imposing on Virginia employers were legal. Yet two federal courts have held they are not.

In King v. Burwell, four Virginia taxpayers are challenging the IRS’s decision to impose Obamacare’s major taxing and spending provisions in states that refused to establish a health-insurance “exchange.” As provided in the Affordable Care Act, the federal government established fallback exchanges (HealthCare.gov) in those states.

But the act authorizes premium subsidies — and certain taxes that those subsidies trigger — only “through an Exchange established by the State.” In spite of that clear statutory requirement, the IRS is issuing premium subsidies and imposing those taxes in 34 states, including Virginia, that did not establish exchanges. The King challengers allege the IRS is subjecting them, Kevin Pace and 57 million other Americans to illegal taxes in the form of Obamacare’s individual and employer mandates. The Supreme Court heard oral arguments earlier this month, and will likely rule by June.

Times-Dispatch columnist A. Barton Hinkle’s “The case against Obamacare is looking weaker,” March 23 — is skeptical of the challengers’ claim that Congress intended to authorize the disputed taxes and spending only in states that established exchanges. I used to share his skepticism. I no longer do.

When the Supreme Court drops its big ObamaCare ruling this summer, Republican leaders say they will be fully ready to step in — even if it won’t be the party’s official replacement plan.

“We have to be prepared, by the time the ruling comes, to have something. Not months later,” House Ways and Means Committee Chairman Paul Ryan (R-Wis.) told reporters this week.

Ryan said he plans to have a bill ready — and priced by the Congressional Budget Office — by late June when a ruling for King v. Burwell is expected. The GOP-backed case, which threatens to erase people’s subsidies in about three-quarters of states, has tremendously high stakes.
“There are going to be 37 states immediately impacted, or presumably impacted, and that’s something that deserves an immediate response,” Ryan told reporters.

He declined to provide details about the plan that he and other GOP chairmen are drafting, but said it would offer “freedom” and “more choices” for any ObamaCare customers who loses their subsidies. Until the ruling, he said King v. Burwell will be one of his top three agenda items.

Breaking with normal tradition, we’re going to open this week’s update with national trends before moving into updates at the federal and state levels. This week there was an interesting report from the Kaiser Family Foundation that estimated that 50 percent of households receiving financial assistance to purchase private health insurance on the Marketplaces will have to return a portion of that subsidy when they file their tax returns as part of the tax credit reconciliation process. Repayments will, in most cases, be deducted from an enrollee’s refund check and the Kaiser report estimates that the average repayment will be $794. Roughly seven percent of enrollees could owe a repayment of between $2,000 and $5,000 and two percent could have to repay more than $5,000. A slightly smaller percentage of households, 45 percent, are estimated to receive additional money with their tax refund because they received underpayments in tax credits, with the average refund estimated to be $773. Kaiser’s report comes the same week as an unrelated but equally insightful analysis from Avalere found that for Open Enrollment 2 (OE2), ACA Marketplaces were primarily successful in enrolling lower-income persons eligible for subsidized coverage. The report found that as a person’s income went up, they were less likely to enroll in ACA coverage through a Marketplace, with only two percent of persons eligible for Marketplace coverage, but earning more than the amount to receive a subsidy, enrolled in a plan through a Marketplace.

With many Marketplaces and the Federally-facilitated Marketplace currently offering a Special Enrollment Period (SEP) for those currently uninsured who did not have health coverage in 2014 and are subject to the “shared responsibility payment” when they file their 2014 taxes, there have been few updates on how many eligible persons are taking advantage of this opportunity to gain coverage. However, over the weekend Mark Ciaramitaro, a vice president of health-care enrollment services at H&R Block, told the Wall Street Journal “that a significant percentage of taxpayers whose household members were not covered for at least a portion of 2014 are opting” to pay the penalty for not having coverage and not demonstrating an interest in signing up for 2015 coverage.