Articles on the implementation of ObamaCare.

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.

More than a year after egregious security failures in the government’s healthcare website were exposed in congressional hearings, data remains compromised and the ill-fated site is still subject to cyberattacks and vulnerable to massive identity theft.

In fact, just this week Judicial Watch obtained documents from the government that show a possible mass breach of the privacy of innocent Americans involving the disastrous Obamacare website (Healthcare.gov). The records, from the U.S. Department of Health and Human Services (HHS), also reveal that top officials with the Centers for Medicare and Medicaid Services (CMS) knew of massive security risks with the healthcare website but chose to roll it out without resolving the problems.

When the Obamacare internet drama blew up in the administration’s face the Department of Homeland Security (DHS) was called to help clean up, according to the records recently made public by JW. Electronic mail exchanges between various DHS and CMS officials indicate that White House pressure to promote a “robust” digital Obamacare ad campaign allowed private information of Healthcare.gov users to be shared with advertisers. The email chain pushing this controversial use of citizen information includes a security expert’s assessment that security was an “afterthought” on the Obamacare website, that 70,000 Healthcare.gov records were easily viewed using Google and that the official in charge was fired for not signing off on the website’s security.

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.

The Affordable Care Act, signed by President Obama five years ago this week, sparked a host of changes. For some workers, the law’s legacy amounts to fewer hours of paid work.

The law’s requirement that larger employers provide affordable insurance to workers putting in 30-plus hour weeks has led some companies to cap the number of hours employees can log. A new survey out Tuesday from the Society for Human Resource Management finds that 14% of employers have cut back on hours for part-time employees, and an additional 6% plan to do so. The survey, which included more than 740 human resources professionals, found that a small subset of companies were considering reducing hours for full-time employees too.

Firms are playing around with how they classify and schedule workers, but the strategy comes with risk. James Napoli, a partner with Seyfarth Shaw LLP who helps employers comply with the ACA, says he’s seen an uptick in audits focused on compliance with the health care law by the Department of Labor and the Internal Revenue Service. The audits, which began about three years ago, are starting to become broader, more frequent and more serious, he said.

Six Democratic senators and one independent have asked the Department of Health and Human Services to a delay a new rule that would likely force small businesses to pay more for employee health insurance under the Affordable Care Act, aka Obamacare. The senators warn that if the administration goes ahead with the change it would be “particularly harmful and disruptive” to small businesses.

Starting in 2016, the Obamacare change will require businesses that employ between 51-100 people to purchase insurance in what the government defines as the “small group market,” rather than the market for large group plans. The senators warn that the change will inflate health care costs for those businesses.

“[T]hey could experience higher premiums, less flexibility, and new barriers to coverage. We therefore encourage you to delay the effective date in the definition change for two years so the market can more smoothly transition to the new rules,” the senators wrote in the March 12 letter to HHS Secretary Sylvia Burwell.