The impact of ObamaCare on doctors and patients, companies inside and outside the health sector, and American workers and taxpayers

The U.S. public has been split in their views on the Affordable Care Act since the law was enacted in 2010, but what about those Americans who actually buy their health insurance through the federal program’s marketplaces?

Although most Obamacare participants give high marks to their health coverage, a growing segment of ACA exchange users has expressed frustration with rising costs and what they see as a shortage of plan options. According to the Henry J. Kaiser Family Foundation, the share of Obamacare enrollees who are dissatisfied with their plans rose from 14 percent in 2014 to 29 percent in 2016.

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The latest Kaiser Health Tracking Poll finds that health care is among the top issues, with the economy and jobs and immigration, Americans want President-elect Donald Trump and the next Congress to address in 2017.

While the average estimate shows nearly 21 million people have benefitted from Obamacare, it’s important to note that some people currently enrolled in Medicaid could have enrolled in Exchange coverage with nearly full subsidization had their state not expanded Medicaid, and would likely be eligible for whatever new subsidy structure might replace the current system. Regarding those in the Individual Market, not all of these individuals are receiving subsidies and would therefore not be financially impacted by the repeal. Making reasonable assumptions and accounting for those who lost insurance because of the ACA, and setting aside any assistance that would be provided by ACA replacement policies, the number of people who, on net, are potentially at risk of being negatively impacted is likely closer to 13-14 million.

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My colleague Avik Roy has suggested that passing a full Obamacare replacement (as opposed to a partial replacement passed via reconciliation) might be possible even though it would require Democratic votes to obtain the 60-vote threshold in the Senate, and that a pre-condition to achieving that would require the Congressional Budget Office (CBO) score the replacement as covering at least as many people as the Obamacare does.

As if to give a warning shot across the Republican bow, the officially non-partisan CBO warned that it “would not count those people with limited health benefits as having coverage” when evaluating changes to the health care law, and that changes to the “essential health benefits” required under the ACA could result in people receiving tax credits to help pay for health insurance under a new law, but being counted as not having health insurance according to the CBO, if the coverage they have doesn’t meet the CBO’s requirements. At issue, basically, is “What is health insurance?”

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As Congress readies legislation to repeal and replace the Affordable Care Act (ACA), Congressional Budget Office (CBO) estimates will play an important and respected role as they did in the passage of the law in 2010. We now know that many of CBO’s projections of important aspects of the ACA have significantly differed from actual outcomes. In this piece, I highlight CBO’s key past errors in projecting effects of the ACA. They can largely be grouped into two categories. First, CBO projected that the exchanges would be stable by now with more than twice as many enrollees as they currently have, rather than suffering from severe adverse selection in most states as they now are. Second, CBO projected that the ACA Medicaid expansion would be much smaller and less expensive than it has turned out to be.

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Cost overruns are endemic to government health programs, and ObamaCare is turning out to be no different. Not only are its Medicaid expansion costs exploding, skyrocketing premiums are now pushing insurance subsidy costs through the roof.

A new study from the Center for Health and Economy finds that because of the double-digit premium increases across the country, federal spending on ObamaCare’s insurance subsidies will shoot up by nearly $10 billion next year

That’s because the amount of the subsidy is directly tied to the cost of insurance in any given market. The Obama administration treats this as a cardinal virtue of ObamaCare, because the subsidies largely shield eligible enrollees from premium rate shocks. In fact, the administration has argued that higher premiums are a good thing, because they make more people eligible for those subsidies.

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In the midst of open enrollment for Obamacare, there is plenty of bad news for health law supporters, from skyrocketing premium rates to diminished insurer participation. Public opinion remains steadily opposed to the law.

After a fluid first few months in 2009 as the plan got underway in Congress, public opinion of Obamacare settled into a consistent trend in early 2010, with opposition outweighing support—often by a sizable margin.

Gallup’s tracking, for instance, shows that since the law took effect in 2013, a majority of Americans have consistently disapproved of it, ranging from a low of 48 percent in July 2015—just after the Supreme Court’s ruling upholding the law’s federal subsidies—to a high of 56 percent.

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During 2015, the growth in both individual-market and employer-group coverage resulted in a net increase in private-market coverage of 2 million individuals. For individual-market policies, enrollment increased by a bit more than 1.12 million individuals. For the employer-group-coverage market, enrollment in fully insured plans declined by 932,000 individuals, while enrollment in self-insured plans increased by 1.86 million individuals. The net effect of those changes was an increase of 926,000 in the number of individuals with employer-sponsored coverage in 2015.

Public program enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) increased by almost 2.77 million individuals in 2015. As in 2014, the change in Medicaid enrollment in 2015 differed notably between states that adopted the ACA’s Medicaid expansion and states that did not. States with the ACA’s Medicaid expansion in effect experienced Medicaid enrollment growth of almost 2.13 million people, while in the states without the expansion in effect, Medicaid enrollment grew by 640,000 individuals.

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One of the most frequently heard claims from the Obama administration is that Obamacare is responsible for insuring 20 million adults who were previously uninsured. But Heritage Foundation research shows the administration’s figure is off by a few million.

It is important to note that the administration’s coverage estimates are based on survey data rather than calculating the actual change in coverage in different markets. Though surveys can provide useful information, they are not as precise as using enrollment data taken directly from insurance companies.

A recent analysis by The Heritage Foundation’s Edmund Haislmaier and Drew Gonshorowski uses the more accurate method, taking actual enrollment data from Medicaid and private insurance companies to assess the impact Obamacare has had on coverage.

The researchers found that just over 14 million people gained coverage from the end of 2013 to the end of 2015. Of those 14 million, 11.8 million gained their insurance through Medicaid and 2.2 million through private coverage.

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In a recent podcast, Weekly Standard editor Bill Kristol made the observation:

if Obamacare had worked, Hillary Clinton would be the president-elect, right?  I do think those those premiums going up two weeks before the election probably moved the necessary number of votes.

That got me to thinking how one might prove this empirically. The short answer is that I cannot prove this proposition beyond a shadow of a doubt, but the evidence is stronger than one might suppose.

To be sure, national exit polls showed that the most important issues in this campaign were the economy (52%), terrorism (18%), immigration (13%) and foreign policy (13%). However, according to David Wasserman’s definitive vote tallies at Cook Political Report, a swing of only 38,595 votes in 3 states (MI, PA, WI) would have given the election to Hillary Clinton. This represents 0.0293% of votes cast, making it the 7th closest presidential election in history in terms of this metric (p. 330). The issue for our purposes here is whether we could make a good case that Obamacare was the factor that led these crucial election-deciding voters to pull the lever for Trump rather than Clinton.

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