If you want to really impress your boss, you should under-promise and over-deliver. But with the Affordable Care Act, Democrats did the opposite when it came to the voters who elected them: They over-promised and under-delivered. 

Listening to Democrats during the debate over the 2010 law, and in subsequent years as it was implemented, you might be forgiven for imagining a post-Obamacare world where the sun suddenly shone brighter, you could always get in quickly to see your doctor and it wasn't necessary to worry about the cost of medical care because your insurance plan was happy to pick up the whole tab, no questions asked. Seven years ago, Democrats eagerly made rosy predictions about how the ACA would improve the health-care system. In one memorable description, top House Democrat Nancy Pelosi (Calif.) boiled a post-ACA world down to one thing -- happiness.

“A healthier life, the liberty to pursue happiness free of the constraints that lack of health care might provide to families … under the Affordable Care Act, you have that ability – that liberty to pursue your happiness," Pelosi said in March 2012.

Democrats have since been forced to tone down their praise of Obamacare and acknowledge its shortcomings as the marketplaces created by the law have suffered under rate spikes and fewer plan options. Some important components of the ACA fell apart -- including its array of nonprofit health-insurance cooperatives that were supposed to improve marketplace competition. And the insured rate hasn't fallen as much as originally projected (although some of that is due to states refusing to expand Medicaid).

The Republican National Committee seized on comments yesterday by Zeke Emanuel, a prominent advocate for the ACA who also said it needs fixing:

To be clear, the ACA hasn't come anywhere near to destroying the U.S. health-care system like many of its overly zealous critics warned. But The Health 202 wouldn't exactly give Obamacare -- at least in its current form --  an A , either. There are a lot of reasons for this, but most bipartisan observers agree that President Obama's signature achievement needs some significant fixes.

Here's a look at some of the biggest promises Democrats have made about he ACA, which have either fallen short or failed to materialize entirely:

The promise: President Obama set some high expectations for how his health-care law would work, promising it would offer customers a wider array of plan options than prior to enactment. Here's what Obama said from the White House on Oct. 1, 2013, the first-ever day of ACA marketplace enrollment: 

"You enter some basic information, you’ll be presented with a list of quality, affordable plans that are available in your area, with clear descriptions of what each plan covers, and what it will cost.  You’ll find more choices, more competition, and in many cases, lower prices."

The reality: There are several plan options in some state marketplaces, but as many as 815,000 shoppers could have just one or no marketplace options next year, according to research by the Robert Wood Johnson Foundation. The number of counties nationwide with just one participating insurer skyrocketed last year, and could run even higher in 2018.

The promise: Pelosi stressed in March 2014 that people would have an easier time affording their coverage under the health-care law.

"I believe it's a winner. By the way, it's called the Affordable Care Act; it's called the Affordable Care Act...Affordable. Affordable. There’s a reason. Affordable. Affordable. Affordable. Affordable. Affordable....Whatever it is, it is infinitely more affordable than the path we are on without it."

The reality: Millions of Americans are now getting federal subsidies to help pay for their plans, so Pelosi's correct in a sense. But there's widespread agreement that the subsidies aren't generous enough for people who qualify at the higher end of the income spectrum, leaving middle-class Americans without employer-sponsored coverage still struggling to pay their premiums. And even if they can afford those premiums, many families face skyrocketing deductibles, as insurers have looked for ways to cover their costs as they're required to offer more benefits.

Half of all marketplace enrollees earning between 300 and 400 percent of the federal poverty level (around $36,000 to $48,000) face spending that's greater than 14.5 percent of their income, a 2016 Urban Institute study found. The costs were even higher for people with significant medical challenges. Ten percent of enrollees earning between 200 and 500 percent of the poverty level (around $24,000 to $59,000) pay at least 21 percent of their income toward premiums and out-of-pocket costs, according to the study.

The promise: Pelosi claimed the law was lowering the cost of health care in a May 2013 interview with MSNBC's Chris Hayes:

"The Affordable Care Act is bringing the cost of health care in our country down in both the public and private sector. And that is what is largely responsible for the deficit coming down."

And in February 2014, then-House Budget Committee ranking Democrat Chris Van Hollen  (Md.) told MSNBC's Chuck Todd this:

"In fact, the Affordable Care Act, as you know, has resulted in significantly reducing the per capita cost of health care."

The reality: National health spending and per-capita health spending have never decreased -- they have just grown more slowly. And the slow recovery from the recession is the much more likely reason for slower growth rates in the years right before and after the ACA was passed. National health spending has been creeping back up, growing 5.8 percent in 2015. And last year, per-person health-care spending exceeded $10,000 for the first time ever.

The promise: President Obama said millions of Americans would get rebates from their insurers under a provision in the ACA requiring insurers to give back money if they spent more funds on overhead than allowed. In a July 2013 speech at the White House, Obama said "13 million (health insurance) rebates went out, in all 50 states. Another 8.5 (million) rebates are being sent out this summer, averaging around 100 bucks each."
The reality: Obama had the numbers pretty much right. In 2012, insurance companies returned $1.1 billion to about 12.8 million policy holders, according to the Centers for Medicare and Medicaid Services. But there's a catch: About 61 percent of that money went to employers, since a majority of Americans receive health coverage through their workplaces. And while employers have to use the money on health care, they don't have to directly rebate workers.



AHH: President Trump tweeted this yesterday, after Veterans Affairs Secretary David Shulkin announced the VA will be replacing its electronic health records with a better commercial product used by the Pentagon:

For years, government auditors have criticized the poor condition of the VA's medical records system. Shulkin said Monday that the new IT system will be used to schedule VA medical appointments, hopefully reducing wait times for veterans, the AP reports. Remember the backdrop to all of this: the 2014 scandal involving long waits at the Phoenix VA medical center.

Improving the VA's medical records is apparently a health-care happy place for members of both parties.

OOF: Obamacare didn't spur more competition in the individual insurance market, as its supporters had originally promised. And there are far fewer insurers than before its exchanges went online. But has the law destroyed the market? Not exactly. The New York Times has some cool graphics explaining a recent study comparing the pre-ACA market to the post-ACA market. A few of the most interesting tidbits include:

--There were 529 insurers in the individual market in 2013, the year before the marketplaces opened. Just 357 insurers sold plans in 2014, the marketplaces' first year, when they were required to offer more comprehensive coverage. This year that number has dipped again -- but just by a little -- down to 323 insurers.

--There's been a big shift since 2014 in where insurers are selling individual policies. One-third of them are choosing to sell outside the marketplaces, where their customers can't get federal subsidies.

--The most competitive states have always been that way. There are 15 states where eight or more insurers offer Obamacare plans. They are mostly the same ones where no single insurer had a dominant share of the market in 2013, before the marketplaces opened.

OUCH: The United States has one of the largest disparities between health outcomes for the richest and poorest Americans, the Post's Carolyn Y. Johnson reports. Only Chile and Portugal had a wider gulf, according to a study of 32 rich and middle-income countries published in the journal Health Affairs,

"Of people in households making less than $22,500 a year, 38 percent reported being in poor or fair health in a survey taken between 2011 and 2013. That's more than three times the rate of health troubles than faced by individuals in households making more than $47,700 a year, where only 12 percent of people reported being in poor to fair health," Carolyn writes.

--The U.S. also has more people who go without needed care because they can't afford it, according to the study. "In the Philippines, the gap between the rich and poor skipping care because of cost was the greatest. But the United States was second on the list; 1 in every 5 people in the bottom third of income reported skipping medical treatment because of the cost. In the top third, only 1 in every 25 Americans did," Carolyn writes.


--Today when Senate Republicans meet, they'll be able to view some legislative options for a possible health-care bill. Now this isn't text, mind you, but concepts that could be turned into legislation. Committee staff can't actually write a bill they're certain is viable under budget reconciliation rules until they hear from the Senate parliamentarian on which parts of the House bill pass muster. But GOP leaders are trying to push the wagon forward despite the holdup and amid ongoing disputes over how to handle the Medicaid program. 

“We’ve been talking about this for seven years, so now is the time to start coming up with some tangible alternatives and building consensus,” Sen. John Cornyn of Texas, the Senate's No. 2 Republican, told the AP yesterday. Sen. John Thune (R-S.D.) the No. 3 Republican, said he's hoping for a vote this month but said it will "certainly" happen before the long August recess starts.

And Sen. Roy Blunt (R-Mo.), also in leadership, told Politico this about the intra-party disagreements: “I don’t think this gets better over time. So my personal view is we’ve got until now and the Fourth of July to decide if the votes are there or not. And I hope they are.”

No. 4 Republican John Barrasso (R-Wyo.) said he remains "optimistic," Bloomberg's Sahil Kapur tweeted:

But there's a big disconnect between what reporters are hearing from leadership and what we're hearing from the rank-and-file. Here's what Sen. Lindsey Graham (R-S.C.) said, according to Sahil:

--Politico also reports that House Speaker Paul D. Ryan (R-Wis.), who guided a version of an Obamacare overhaul to passage last month, is stepping up his fundraising in the wake of the unpopular bill.

"The Wisconsin Republican’s political team on Tuesday morning will announce that Ryan has raised $22 million for House Republicans in the first five months of 2017, setting him on track to far outpace his 2016 fundraising haul," Rachael Bade reports. "Over the same period last year, an election year, Ryan hauled in $16.5 million."

"In the month of May alone Ryan transferred $2 million to the National Republican Congressional Committee," she writes. "And since the House voted on the controversial health care bill, he’s also attended nearly 50 events in 13 states from Arkansas to Michigan and North Carolina to Texas, helping members gearing up to defend themselves from Democrats vying to seize their seats."

In states where a Blue Cross Blue Shield affiliate was the only ACA option, each company turned a net profit in the first quarter, according to an Axios review of financial documents. That's a big turnaround from last year, when most of them lost money.
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  • Facebook will host an invitation-only health summit in New York today for pharmaceutical marketers, CNBC reported, as it attempts to garner ad interest from pharmaceutical companies.
  • Coming up
  • The Bipartisan Policy Center will host a discussion on obesity care. The event begins at 10 a.m. on Wednesday.
  • American Enterprise Institute will host a panel discussion on opioids, community, and the economy. The discussion will begin at 10:30 a.m. on Wednesday.
  • The House Ways and Means Health Subcommittee will hold a hearing Wednesday on Health Medicare Advantage on “Promoting Integrated and Coordinated Care for Medicare Beneficiaries.”
  • The Atlantic will host a discussion on Wednesday at the Newseum in Washington, D.C. on biosimilars and “the policy and regulatory debates surrounding these complex large-molecule drugs.” The event begins at 8 a.m.
  • Health and Human Services Secretary Tom Price will testify Thursday before the Senate Finance committee and the House Ways and Means committee to testify on the administration’s budget for the 2018 fiscal year. The department’s budget as proposed includes more than $600 billion in cuts from Medicaid over the next decade, on top of more than $800 billion proposed in the AHCA. Dems are likely to grill Price about these numbers during Thursday’s hearings.
  • The House Oversight Committee holds a hearing on Thursday morning on the role of the Department of Health and Human Services in health care cybersecurity.
  • President Trump is scheduled to host a fundraiser at his Trump National Golf Club in New Jersey for a Republican lawmaker who played a role in pushing the Republican health care effort through in the House after a failed first bill. Trump will hold the event for Rep. Tom MacArthur on June 11 in Bedminster, NJ. The Associated Press reported donations are suggested between $5,400 and $100,000.

Watch VA Secretary David Shulkin talk about a new electronic medical record system.

Aquaman praises Trump's decision to withdraw from the Paris accord: