Articles on the implementation of ObamaCare.

One of the key questions surrounding Obamacare is just how many people have been newly insured under the law. The answer is clouded by the fact that the White House and others have changed some rules of math for making these assessments.

For example, several years ago, the Obama Administration fiddled with Census Bureau’s definition of what it means to be “uninsured.” The new parameters, which were looser than the old factors, make it hard to construct comparisons between today’s figures for the total number of uninsured and the historical trends.

The Obama team also abruptly started to exclude uninsured illegal immigrants from the national tally on total number of uninsured Americans. Before Obamacare, these individuals were counted in that reporting, inflating the numbers. After Obamacare, these individuals didn’t get insurance, but suddenly didn’t get counted any more.

Now, a new analysis from the highly regarded managed care analyst at Goldman Sachs, Matthew Borsch, and his team, cast uncertainty on some of the recent data releases from the White House, and its network of academicians. In particular, the Goldman breakdown conflicts in some key ways with a recent analysis from RAND that was published in the journal Health Affairs and widely cited by the media.

Has the effort peaked to sign up uninsured Americans for coverage? The announcement that the nonprofit organization Enroll America is laying off staff and redirecting its focus in the face of funding cuts comes amid inconsistent sign-ups during the second Affordable Care Act open-enrollment period and concerns about affordability.

A recent New York Times analysis compared Kaiser Family Foundation estimates of potential enrollees with sign-up data from the Department of Health and Human Services. While some states that signed up few people in 2014 recovered during the 2015 open enrollment, other states lagged: “California, the state with the most enrollments in 2014, increased them by only one percentage point this year, despite a big investment in outreach. New York improved by only two percentage points. Washington’s rates are unchanged.”

Most states could not post consistent gains in both open-enrollment periods. An official from Avalere Health, a consulting firm, told the Times that she was “starting to wonder if we’ve overestimated the whole thing.”

April 15 is right around the corner, and millions of Americans will find themselves paying more in taxes than ever thanks to Obamacare.

The law is more than a fundamental change to the country’s health care system. It also is a massive tax hike. As The Heritage Foundation’s Federal Budget in Pictures shows, according to the most recent scores, Obamacare will increase taxes by nearly $800 billion for the period of 2013-2022.

Obamacare contains 18 separate tax increases. A few of the biggest include a tax on “Cadillac” health insurance plans, which doesn’t take effect until 2018, long after President Obama and many in Congress who voted for the tax in 2010 have departed Washington. Also, there is a tax on health insurance premiums and a higher rate on the Hospital Insurance payroll tax for single filers with incomes above $200,000 ($250,000 for married filers) that also applies to investment income.

Heather Higgins: The thing that I do that spends actually most of my time and is not something that is terribly sexy for donors, but that I think is hugely important is work on Obamacare. That’s kind of how I backed into the political stuff. I had been very involved in 2009 in trying to help fund and orchestrate and message the entire battle against Obamacare because there was no infrastructure on the right that was really set up to do that. And then coming out of that had the epiphany that since Reid and Pelosi were not moving, maybe the way to do that was to go into the Massachusetts race for Ted Kennedy’s seat, that special election which was being run on the issues that had polled well in September, which were the national security issue and the economy, and instead redefine the race as being about healthcare and the 41st vote, which every political consultant I took that to thought that I was on drugs and that that was a waste of money. So we wound up being the only independent expenditure in Scott Brown’s first race to make it be about healthcare and the 41st vote. [Applause.] Thank you.

And then in the summer of 2010 I was appalled that nobody was talking about Obamacare so we created the Repeal Pledge which is actually the only pledge about Obamacare that still exists of the ones that were started then; and coming out of the 2010 election where we had used it, I looked for the group to join to think strategically about not working at cross purposes between what the Senate might do, the House might do, the court case from Florida that was then rising up to the Supreme Court, what outside grassroots group could do, and there was none. So I’ve started something called the Repeal Coalition which meets every 3 to 4 weeks in the Capitol. It has leadership staff from both the House and the Senate. It has a lot of staff from different Members and Senators. It has a lot of outside groups that are policy wonks to grassroots groups, and we talk about all the things we wish that would get done that don’t get done, and we talk about things that sound like good ideas and figure out if they’re dumb ideas and try and prevent dumb things happening. There is an overriding purpose to this which is remembering, of course, the long-term goal.

During the recent oral argument in King v. Burwell — the Supreme Court case deciding if providing subsidies to buy health insurance in the 36 states utilizing federal health care exchanges is allowed under the Affordable Care Act (ACA) — Justice Kennedy suggested that disallowing subsidies might be unconstitutionally coercive because “states are being told either create your own exchange, or we’ll send your insurance market into a death spiral.” Are “death spirals” real, or just a way to frighten the public?

The death spiral will purportedly happen like this: disallowing federal exchange subsidies will make insurance less affordable for the 87% of federal exchange enrollees currently receiving subsidies. These people will no longer be required to buy insurance since the ACA’s individual mandate only applies to individuals who have access to affordable insurance. Since the ACA imposes community rating, requiring roughly the same premium for all individuals in a given plan with only small adjustments for their risk characteristics, and guaranteed issue of insurance regardless of the enrollee’s health, the old and unhealthy will continue to buy coverage but the young and healthy will forego coverage. The resulting higher risk pool of enrollees will increase the average cost of individuals remaining in the non-group insurance market, both on and off the exchanges, resulting in increased premiums that will drive out more low cost, healthy patients eventually destroying the market.

Two economic simulations predict that “adverse selection,” where healthier people leave the insurance market and sicker people stay in causing premiums to rise, will occur if the King plaintiffs prevail. The Urban Institute predicted discontinuing federal exchange subsidies would result in premium increases of 35% and enrollment declines of 69% in the individual health insurance market. The Rand Corporation made similar predictions.

But it is hard to reconcile these forecasts with studies of earlier state insurance market “reforms” that created market conditions similar to those that would result if federal exchange subsidies are disallowed. These studies suggest adverse selection would be minimal and would not lead to a “death spiral,” that is, it would not lead to a self-reinforcing cycle of adverse selection in which each time premiums rise, more people exit, leading to a sicker, more expensive risk pool and market collapse.

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.