There was a time, way back in 2009, when health care reform was about something rather straightforward. For 47 million United States residents, the health insurance market simply wasn't working. The products cost too much or the providers turned away customers or people just didn't have space to sort it all out in between two part-time jobs. So lopsided majorities of people agreed in poll after poll: There needed to be at least one publicly run option, a simple and affordable choice for those who wanted it. We've traveled a long, winding road from that consensus, passing through death panels and individual mandates and a spectacular failure of a website launch. And now, the big question of the moment is this: Has the journey actually taken us someplace new?
The first set of data toward answering that question is just about all in, and it's ominous, if not conclusive. On March 31, the open enrollment period for the Affordable Care Act will close. People can continue signing up for Medicaid all year long, in accordance with their state's rules. But anyone who hasn't purchased an insurance plan on the new exchanges by March 31 will have to wait until 2015 to get coverage. It's a significant milestone for the law. After six intense months of cajoling people to sign up and arguing over the mistakes and scrutinizing crumbs of data, there will be a final tally of how many uninsured Americans have found the new insurance market more viable than the old one.
One of the challenges of truly measuring the law's success--and that of our health care system more broadly--is that we continue to discuss "the uninsured" in vague terms, as a monolith of consumers who've shrugged off risk and chosen to spend their money on something else. That notion has become more ingrained in recent months as everyone from the White House to the news media has focused intensely on the number of young, presumably healthy people who have signed up for Obamacare. Their participation is crucial to bringing down overall costs, and they've been slow to join. At month's end, this is the number everyone will be eager to hear; it is the agreed upon measuring stick for the law's success or failure.
But there's another, less discussed measure of the Affordable Care Act's success, one that more directly addresses the actual problem the law needs to solve. That is the number of working poor people who have gotten insurance because of Obamacare. It's important to understand whom we're talking about when we refer to "the uninsured." Three out of four uninsured people had jobs in 2013; three out of four made less than 250 percent of the federal poverty level in those jobs; and more than half were people of color, according to the Kaiser Family Foundation.
A map of where those people live renders the United States as a layer cake. They're most densely clumped in a band stretching all the way across the South; then with a little less density across the middle of the country, from the Plains to the Mid-Atlantic; then most loosely at the top, from the Upper Midwest to the Northeast. The map would also serve fairly well as a breakdown of states that have and have not grown their public health insurance programs over the past 20 years. And it'd offer a pretty good reflection of the states that have refused to join Obamacare's expansion of Medicaid. Seventeen states had uninsurance rates over 18 percent in 2012; two-thirds of them have opted out of Medicaid expansion. So in the places where the actual problem is most acute--namely, the working poor being unable to buy insurance--the law's most direct fix isn't even in play.
But even where Medicaid is expanding, it doesn't take a huge paycheck to miss out. A retail worker making $17,000 a year and living in Newark, N.J., wouldn't qualify, for instance. She would, however, qualify for a subsidy to purchase one of at least 26 insurance plans for sale on the state's exchange. Problem is, the evidence thus far suggests people like her are still finding the product too expensive and too complicated for their lives.
"A lot of people, they voice to me that they like the idea of the Affordable Care Act," says Gabrielle Terry, who's been working since October as a "navigator" trying to enroll people in Newark. "What's happening to them is, you put your income into this portal, and they give you numbers for what they think you can afford," she says, explaining the enrollment process. "But they don't really know your expenses. So they think you can afford a $300 premium because you're getting paid this amount of money, but they don't know about your other kids, or if you're taking care of your niece who--" she stops, frustrated by trying to explain the gap between real lives and the qualification formulas applied to them. "Whatever. They don't know about that."
When I spoke to Terry in early March, she had still not seen a single person go all the way through the enrollment process and actually buy insurance. In fact, none of the navigators I interviewed in Newark had seen it happen. Federal data suggest navigators around the country are finding similar results. As of March 1, fewer than 15 percent of uninsured people who would qualify to enroll had done so, according to Kaiser.
There could be all kinds of reasons for this relatively low rate, starting with insufficient resources for outreach to those people in many states. It's also important to note that Medicaid enrollment appears to be going quite well. But the relatively low rate of people buying insurance, even with the help of a subsidy, suggests the testimony I've heard from Newark navigators is true widely--that the working poor are doing the math and deciding the insurance market still fails them.
The new insurance exchanges are built to make things easier by leveraging market forces. They create a set of rules that, ideally, make it easier for consumers to shop around, by diversifying the number of providers and making their products easier to understand. Plans are divided into tiers based on the cost of the monthly premium and uniformly categorized by Olympian names--bronze being the cheapest, platinum the most expensive. Still, the navigators I spoke with said people remain overwhelmed by the effort to be savvy consumers of a product with such grave consequences.
"It scares them. They're scared," says Khalilah Jackson, another Newark-area navigator. "And I can totally understand." If a subscriber chooses a cheaper plan to stretch a just-above-minimum-wage paycheck, will he be able to actually use the insurance when faced with large co-pays and deductibles and other cost-sharing rules down the line? Many are simply saying screw it, and choose to take the relatively modest tax penalty next year rather than fuss with the no-win calculus of the marketplace.
So Obamacare's two efforts to get coverage for the working poor--who account for the vast majority of the uninsured--is off to a difficult start. The states in which Medicaid could do the most good have rejected it. The people whom the exchanges are supposed to attract are opting out. All of that before acknowledging that no immigrant who is undocumented or who has been in the country less than five years can qualify for either Medicaid or a purchasing subsidy.
Ultimately, these enrollment challenges beg larger questions about the whole enterprise. Given who the uninsured really are, can a rejiggered, market-driven system actually serve them? Even if they buy insurance on the exchanges, will care providers be able to meet the needs of their complex lives while remaining profitable? Are there enough doctors who even accept Medicaid, given the low payments they receive for those patients? Time will tell. But if the past six months are a fair measure--and given the toxic political climate in which the system has operated, perhaps they are not--Obamacare will not be the final word on the nation's health care crisis.