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The Agenda

NRO’s domestic-policy blog, by Reihan Salam.

Obamacare’s Worst Metric by Far: Covering the Uninsured



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After its first round of enrollment, the Affordable Care Act has enrolled the number of Americans expected in private insurance coverage and apparently signed a lot of people up for Medicaid. In one major way, the law is working. But the most fundamental task of the law was reducing the number of Americans without health insurance, so it is hardly a cheap attempt to distract from the enrollment success to point out that it seems to be doing a rotten job of signing up the uninsured. Chris Conover, a Duke academic who blogs at Forbes with Avik Roy, has drawn up the below chart, comparing the share of uninsured Americans who’ve gained coverage by this point versus each of the CBO’s projections about the law.

It’s doing absolutely terribly on this metric versus projections, to say nothing of rhetorical claims about vastly expanded coverage):

That is, even after many states rejected the Medicaid expansion and the HealthCare.gov debacle of last fall, the CBO still expected the law to cover twice as many of the uninsured as it did. Conover makes the right point: If the CBO had projected Obamacare would do this in its first year — disrupt individual markets and raise premiums for millions while covering one in eight uninsured Americans, it’s hard to see how the law would have passed. 

I should note that I consider Conover’s projections pretty conservative: I find it a little hard to believe 1 million people who were paying individual-market premiums before their plans were canceled are now going uninsured (if so, wow, this law is worse than I thought). The estimates about how many of the exchange enrollees were previously uninsured are still unreliable. People may be not becoming uninsured thanks to the ACA even if they had insurance last year. Etc. But Conover doesn’t adjust for enrollees not paying their premiums, and he’s doing careful work, so his basic conclusion is almost surely right: The law isn’t meeting significantly lowered projections of how many insured it would cover.

Here is the disheartening thing: Conservatives can talk all they want about whether Obamacare is covering the uninsured and doing so at a reasonable cost. But now that enrollments are no longer minuscule and because the exchanges, while they will be troubled and more costly than they should be thanks to a number of factors, aren’t going to experience a death spiral, the law is solidifying its position. Americans don’t like their own insurance being disrupted, and they don’t like obviously disastrous government programs. But they aren’t automatically exercised by wasteful government spending or having millions of Americans uninsured — look, for decades, they’ve tolerated spending hundreds of billions of dollars being spent every year on an insurance program (Medicaid) that doesn’t clearly improve health outcomes.

“It’s not covering the uninsured in the way it promised while causing massive disruption to the individual insurance market” is not as persuasive or alarming as “it’s totally unsustainable” or “it’s not expanding insurance coverage as much as it should.”

“It’s still not covering the uninsured the way it promised while imposing huge hidden costs on the health-care market,” which will have to be the Republicans’ line in 2017, is even less automatically persuasive. All of which, of course, is why as Reihan writes, echoing Ramesh, Obamacare won’t defeat itself.



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