Eight questions that will decide whether Obamacare is a success

October 16, 2013

In a new paper for the Brookings Institution, Sheila Burke and Elaine Kamarck try to identify the "questions that will determine the long-term versus the short-term success or failure of the law."

(Photo by Jessica Rinaldi/Reuters)
(Photo by Jessica Rinaldi/Reuters)

The thing you're hearing about now -- the crummy launch of the federal insurance portal -- is a short-term problem, they write:

There have been computer problems and undoubtedly will be more as the exchanges are opened. In addition, there may well be problems in determining the correct amount of a subsidy a person should get. For a short time at least, some people may get more than they deserve and others less. In fact, the District of Columbia has announced a delay in being able to determine if enrollees are eligible for Medicaid or for government subsidies because of high error rates in the testing phase. Undoubtedly, some unscrupulous people will figure out ways to game the system before the government shuts it down. But these are the sorts of problems that will be worked out. We put them in the category of “short-term” problems because they are expected with an undertaking this large and because the federal government has significant expertise in administering large national subsidy programs.

So what are the long-term measures? There are eight of them:

  1. Is there a reduction in the total number of uninsured?
  2. Is there an increase or stabilization in the cost of premiums on the exchanges and in the private market?
  3. Is there an adequate number of plans in the exchange and does the number increase or decrease over time? Are plans exiting or entering the market over time?
  4. Does the number of people who pay the penalty for not having insurance increase or decrease over time?
  5. Is there a decline in employer coverage?
  6. Is there a decline in full time-work and an increase in part-time work?
  7. What is the extent of the conflict between federal and state oversight of health insurance and does it increase or decrease over time?
  8. Is there evidence of an increase or a decrease in out-of-pocket expenditures on health care?

I'd add one question and one caveat.

First, the question: Is the growth in national health expenditures above or below trend? As one of the law's architects pointed out to me on Tuesday, the early take on Obamacare was that it was going to be a major success in expanding access but it didn't do enough to control costs. So far, however, the access expansion has been more troubled than most expected, while cost control has been far more of a success than anyone anticipated. That's a trend worth following.

Second, the caveat: Short-term problems can become long-term problems. Take the difficulties accessing the federal exchanges. If those persist much longer, it could change the mix of people who ultimately sign up.

The people who really need insurance -- so, sicker folks -- will keep coming back until they get through. But younger, healthier people will give up after a try and decide to simply pay the fine, at least in year one. That would tilt the risk pool in states with federal exchanges towards older, sicker people, which would mean those states will see much higher premiums in year two, which will further dissuade healthier applicants from signing up, and so on. So that's a case where a short-term problem could become a long-term one.

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Andrea Peterson · October 16, 2013