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Outside Washington, Obamacare doesn't exist

Pete Souza/White House

You've heard that Obamacare has signed up 8 million people. That's true, but incomplete. Eight million is just the number who've signed up through the law's insurance exchanges. Another 3.5 million or so have signed up for the law's Medicaid expansion.

This is how we talk about Obamacare: as one thing, or maybe as two. That made sense during Washington's long argument over Obamacare. But it's a huge mistake when talking about the insurance people are actually buying and using in Florida or Oregon.

Obamacare isn't an iPhone; it's not a single, carefully tended experience controlled by a central authority. It's more like the Android operating system. Obamacare powers hundreds of different health systems. Many of those systems are off to an incredible start. Others are struggling.

This is the problem with trying to say whether Obamacare is a success or a failure. The program will end up seeding many huge successes — and some painful failures. It depends on who you are, and where you live. A few things to keep in mind:

1. Obamacare created new private insurance markets in 50 states and the District of Columbia. Some of these exchanges are being run by the states. Most are being run by the federal government. All of them have different risk pools, different insurance choices, different prices.

2. Even that understates the number of Obamacares out there. States have broken their exchanges into sub-exchanges serving different regions. "These are completely state based, if not locally based, insurance markets," says Caroline Pearson, vice president at Avalere Health. "The options available to a consumer in one city versus another city are dramatically different." In California, for instance, there are 19 different regions, each with its own insurance options and prices.

3. California's exchange looks like a wild success. According to Charles Gaba, who's done the best job tracking Obamacare enrollment (read Vox's profile of him), it's already beaten enrollment projections — and the number is still rising fast. That means customers in California have tons of insurance options and a massive amount of competition — and are likely to have even more next year.

4. The poster child for Obamacare failure is arguably Mississippi. They left their exchange to the federal government. There's been almost no outreach so they're lagging way behind enrollment projections. The only insurer participating on the exchange is Humana. Mississippians are looking at a bad risk pool and almost no competition. It's possible that prices will rise sharply in 2015 or 2016.

5. That means the experience of buying insurance through the state-run Covered California exchange has almost nothing in common with the experience of buying insurance through the federally-run Mississippi exchange. Covered California might prove a wild success while Mississippi's exchange could collapse. Talking about Obamacare as a single thing paves over this huge difference.

6. Obamacare's Medicaid expansion also varies wildly by state. An analysis by Avalere Health found that just 10 states are driving 80 percent of the Medicaid enrollments. Right now, 24 states aren't participating in it at all (though at least five of them are considering accepting it). In those states, Obamacare's Medicaid expansion simply doesn't exist.


7. Here, too, the experience of a Californian and a Mississippian are totally different. A family of three living in Los Angeles making $17,000 a year can walk into a community health center and walk out with Medicaid coverage. That same family in Mississippi isn't eligible for Medicaid — or for subsidies on the insurance exchange.

8. Some states, like Arkansas, accepted the Medicaid expansion but only under the condition that they could dramatically reshape their Medicaid program. So a Oregonian using Obamacare's Medicaid expansion and an Arkansan using Obamacare's Medicaid expansion are in very different programs.

9. A Gallup survey released Tuesday morning showed that the uninsured rate is falling three times faster in states that both built their own exchange and accepted the Medicaid expansion. So buying into Obamacare matters.


10. That said, some of the states struggling the most were enthusiastic about the law. Oregon and Hawaii both built their own exchanges — but the exchanges were riven with technical problems. So both are lagging in sign-up. And some states that fought the law, like Florida, are seeing huge numbers of people sign up.

11. "If you're just looking at exchanges then politics is not instructive," says Pearson. "In Florida, the governor banned the navigators from the public-health departments. But they've done quite well with sign-up. Partly that's because it's been the focus of big outreach efforts. But then I can't explain why Texas hasn't seen the same numbers."

12. Some states are trying to transition Obamacare in more radical directions. Beginning in 2017, states can obtain waivers to reshape the program almost entirely, so long as they're able to meet certain targets for coverage and cost. Vermont intends to use that authority — and the funding its getting from Obamacare — to build a single-payer system.

13. Obamacare is a much more state-based approach to health reform than most realize. The upside of that approach is it permits plenty of experimentation, and that might lead to some truly remarkable successes. The downside is it gives states plenty of room to fail, and some of them will.

Correction: This piece originally said 23 states weren't participating in the Medicaid expansion. It's actually 24. The text has been corrected.