clock menu more-arrow no yes mobile

Why Obamacare can fail and succeed at the same time

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

What even is Obamacare anyway?

Even after eight years, that was the question I found myself pondering yesterday as I read the responses to my piece arguing that, in spite of all the warnings about President Donald Trump’s sabotage, the health care law had actually come out mostly intact after one year under this administration.

I stand by the thrust of the story: Nearly as many people signed up this year and the average monthly premium (accounting for subsidies) dropped. It’s hard to take that as anything less than a testament to the law’s resilience.

But what I came away thinking is: It’s increasingly difficult to assess “Obamacare” as if it is a single entity. Because depending on how you look at it, the law might be a rousing success or it’s fallen far short of what it was hoped to be.

I suppose it’s always been true that a 2,000-page law that created brand-new insurance markets, expanded one of the biggest federal government programs, imposed fresh regulations on a multi-billion-dollar industry, and established whole new agencies to test health care delivery models was never just one thing. But that hasn’t stopped us — or me, anyway — from often treating it that way.

Really, in a sense, there are many Obamacares. Some of them are working; some of them aren’t.

You could start with the insurance marketplaces, which is usually what we mean when we talk about “Obamacare.” In some parts of the country, they are more or less thriving, with a plethora of competing insurers that help to drive down costs and keep insurance affordable for everybody.

But in other areas, costs are too high, forcing all but one insurer out of the market and making it difficult for people who don’t receive subsidies to pay for a plan.

In Massachusetts and California and New York, Obamacare is mostly working. In Nebraska and Wyoming and Alabama, it’s struggling. If you look at Colorado or Texas, some counties have competitive markets and others have monopolized ones.

One situation isn’t more valid than the other. It’s just a potent reminder that it’s really hard to make blanket statements about the law.

”I’d say it’s been true from the start that there were really 50 different Obamacares, or really thousands of different Obamacares when you take into account differences in insurance markets across counties,” Larry Levitt, senior vice president at the Kaiser Family Foundation, told me. “The individual insurance market is still relatively stable in many urban areas, but not so stable in others, and it’s definitely wobbly in rural parts of the country.”

This brings us to the subsidized versus unsubsidized problem. People who receive tax credits to pay their premiums are protected from rate hikes in some of those struggling markets. They are probably here to stay, already making up more than 80 percent of the law’s customers. For them, this is working fine; the average monthly payment actually dropped to $89 this year.

But if you don’t receive any tax credits, your average premium was $522. For a family of three making $90,000 — which doesn’t receive any financial aid — that can be a prohibitive cost.

Some of those people might be fine going without insurance if they’re young and healthy, or they could be the audience for the White House’s proposals to expand cheaper, skimpier non-Obamacare insurance. But if you actually need the kind of robust insurance the law is supposed to offer, you’re in a tough spot.

We haven’t even gotten to Medicaid expansion, which has covered 15 million people in the states that took it, an unequivocal success for even the most hardline single-payer advocate — and yet it has also still left 4 million or so without any health insurance in the states that have refused to expand, with an assist from the Supreme Court.

So Obamacare is both working and not working; it’s mostly fine for many people and a borderline disaster for some others. The uninsured rate has hit record lows and yet one in 10 Americans still lack coverage and many who have an insurance card struggle to pay their share of the bills.

There is still an underlying infrastructure here, one that has eliminated preexisting conditions and set the states where the law is functioning as intended up for success. Preventive services are free to everyone, kids in every corner of the country can stay on their parents’ insurance until they are 26 years old, contraception is free (for now) for women.

John Graves at Vanderbilt made this case to me:

I think the underlying chassis — fundamental reform of private insurance markets, expansion of public subsidies — remains largely intact. That is, regardless of state, most private insurance plans still can’t impose lifetime/annual maxes, the [essential health benefits] remain unchanged, there are strict [out-of-pocket] maximums that plans can’t go over. That stuff is still in place as a singular whole and doesn’t appear to be changing anytime soon, given the failure of last summers repeal/replace efforts.

We’re not going to stop talking about Obamacare, of course, and we probably shouldn’t, for the reasons Graves mentions. But I wanted to follow up and take you through my own thinking and struggles to tell you exactly how this law, in all of its complexities, is actually doing.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.