The Affordable Care Act isn't perfect. It wasn't when Congress passed it in 2010 and it wasn't when its health insurance exchanges opened for enrollment last week. Like most laws, Obamacare never will be perfect.
Yet despite its blemishes, the ambitious reform effort meant to make a dent in the nearly 50 million Americans who currently lack health insurance is the law of the land. The Supreme Court and the American people both affirmed it last year, developments Republicans are still trying to delete from the record more than a week into a government shutdown they caused in a last-ditch effort to kill Obamacare.
They say the law needs to die in part because President Barack Obama and his administration are going to use it to "destroy everything in America," fulfilling some sort of sick, biblical End Times prophecy.
And in case you thought Republicans weren't serious about hating Obamacare, some party leaders now say they'll go so far as to risk the full faith and credit of the United States if Democrats don't cave to their demands and dismantle the president's hallmark legislative achievement.
The GOP's bloodthirsty pursuit of Obamacare has had serious consequences, among them the elimination of almost all constructive debate over the actual features of the law itself. For many both in and out of Congress, the Affordable Care Act must now be either all good or all bad. Suggesting otherwise could signal sympathy for a suicidal group of politicians hell-bent on ruining the nation -- either with the law or in spite of it, depending on which side of the aisle you're on.
This is a problem. Levelheaded criticism of Obamacare is key to making sure the administration fulfills its promise to expand affordable health care access to millions of Americans. It's not an easy task, especially considering they're trying to do so with a plan forged from borrowed Republican ideas and limited by its creators' refusal to include a public option or pursue a single-payer system or any plan that achieves truly universal coverage.
But just because the law isn't going to bring hell on earth doesn't mean we should ignore its imperfections. Below, take a look at some common questions and reasons we can all be concerned about Obamacare.
1. What happens if not enough people enroll?
As with any insurance program, people will pay for coverage under Obamacare and end up not using it. Healthy or safe policyholders in an insurance pool help subsidize all of the insured. That's how insurance works. In the case of Obamacare, the success of the fledgling program will be heavily reliant on younger, healthier individuals, who provide less of a financial drag on the system and make sure sicker, older individuals can receive affordable coverage.
More than a quarter of Americans in the 19- to 25-year-old range are uninsured, according to the latest census. While they'll be able to purchase coverage through the health insurance exchanges -- and many of them will get substantial subsidies to do so -- conservatives and the Koch brothers are hoping to convince college-aged Americans to "opt out" of Obamacare.
Doing this would subject them to a yearly individual mandate penalty that starts at $95 or 1 percent of their annual incomes, whichever is higher. In return they'd get no insurance, meaning they'd have to pay through the nose for any medical care they end up needing. The absence of young people's premiums, as well as their resulting unpaid medical bills and debt, would all make it significantly harder for Obama to succeed, which is exactly what Republicans want.
With too few young and healthy people and too many expensive and sick policyholders in the insurance pools, premium costs would begin to trend upward each year, further discouraging healthy people from buying coverage. This pattern could lead to what the the insurance business calls a "death spiral."
Most experts have expressed confidence that younger Americans will opt to get insured, encouraged by federal subsidies and turned off by the alternative: paying something to get nothing. But it could be difficult to track exactly the rate at which they, or anyone else for that matter, are signing up for coverage in the first couple months of business. The White House is not set to release data on enrollment through the federal health insurance marketplace until November.
2. How will people respond to paying higher premiums?
Obamacare will offer health coverage to millions of previously uninsured or uninsurable Americans at a lower average rate than initially expected. For this system to work, however, the law expects some people who currently have plans on the existing market to pay higher premiums to get coverage through an Obamacare exchange. For those making an annual salary between 300 and 400 percent of the federal poverty level (which is $11,200), federal subsidies will be limited.
For that small percentage of Americans, some key questions emerge. Will the angry cries of those whose rates go up drown out the joyful shouts of those whose rates go down or who never had insurance in the first place? Will they see their premiums as affordable, even without the subsidies offered to poorer people or those whose coverage is more expensive? Will they decide that health insurance is important enough to pay for, even if it costs hundreds or thousands of dollars a year, or will they reject the new market and opt to pay the individual mandate penalty?
These are arguably the biggest unknowns and could determine whether Obamacare is ultimately beset by the enrollment issue described above, and whether it builds enough public support to be politically sustainable.
3. What happens if the newly insured don't understand what they're buying?
The intricacies of health insurance policies are difficult for anyone to understand, and will likely be even more so for those who have never had such coverage before. In the upcoming months, many people will turn to the exchanges to buy health insurance for the first time in their lives. Will they be able to understand it? Do they know what a deductible is and how it works? If they opt for the lowest-level bronze plan, will they be upset the first time they go to the doctor and find the visit isn't free because they haven't met their deductible?
Like all types of insurance, one of the most vital benefits of health coverage is protection against financial ruin. But for many of the newly insured, such a circumstance may be unimaginable unless something terrible has already happened to them. Some consumers, especially those who aren't familiar with the general concept of insurance, may have serious reservations about spending hundreds or even thousands of dollars on a policy they may not end up using.
If dissatisfaction among new Obamacare adopters emerges for these or other reasons, it could make marketing health care plans to the uninsured, or keeping the recently insured on those plans, more difficult.
4. What about the states that didn't expand Medicaid?
Empowered by the 2012 Supreme Court decision on the Affordable Care Act's limits, many Republican governors have declined to include their states in a massive expansion of Medicaid over the past year, despite promises that it would be almost entirely subsidized by the federal government. All together, 25 states have chosen not to act.
According to a recent New York Times report, these states have now left 8 million poor, uninsured Americans ineligible for federal help in getting health care coverage through Obamacare. These people don't qualify for Medicaid under their states' current rules and, in a cruel twist tied to the Supreme Court ruling, make too little to qualify for subsides on the new health insurance exchanges.
The Times reported that this gap includes two-thirds of the poor black Americans and single mothers and more than half of the low-wage workers who do not already have insurance. These people live disproportionately in the Deep South, in states where the health care system is already strained.
A recent study found that beyond denying health coverage to poor residents, these states will also likely see huge increases in spending on uninsured people's unpaid medical bills in the future.
5. Will health care coverage be sufficient for everyone?
A small percentage of individuals who transfer from their current job-based insurance to the exchanges next year may see some drop in the quality of coverage for their dollars. Employer health insurance tends to be good and relatively cheap for workers, primarily because the company pays a significant portion of premiums, and because the cost is tax-free to both the employer and employee. Some of the cheapest, most basic plans under Obamacare may end up providing less comprehensive coverage, and none are required to offer vision or dental coverage, except for children.
For most other people, however, new health care coverage should be compared to the status quo. For those currently uninsured, the coverage provided by Obamacare exchanges is much better than nothing, provided the amount it costs the consumer is low enough to make her feel like she's getting something of value. Many of these people are also poor enough that basic coverage will be free or close to free every month, not counting whatever they'd pay when they actually go to the doctor.
Those people transitioning to the exchanges after buying their own insurance on the existing market will get better benefits than they do now, though the question remains as to how they'll feel about possibly paying more for it.
Access to health care services is another issue. Concerns about a massive, nationwide "doctor shortage" may be overblown, but it's entirely possible that a crush of newly insured people seeking out medical care next year could put a burden on doctors' offices, clinics and hospitals in some regions. This could prove especially problematic in rural areas, where there are fewer medical practitioners.
Issues could also emerge if consumers' expectations of their provider networks under Obamacare don't match up with reality. In order to control premium costs, insurers in the Obamacare exchanges contracted with fewer medical providers than one might typically find in a solid job-based health plan. While access to these doctors is a big step up for the uninsured or those coming from bad insurance, some people may expect they can get coverage wherever they want, when in fact the big hospital down the street isn't in their network. Considering most lower-tier plans under Obamacare don't offer any out-of-network coverage, it's possible that some consumers will go to a doctor who's not on their list, and end up being on the hook for the full cost of the visit.
6. What happens if Obamacare succeeds in some states but fails in others?
The Affordable Care Act is unlikely to create uniform results across the country, especially considering half of states haven't expanded Medicaid and two-thirds passed off their exchanges to the federal government. The performance of those exchanges, some operated by the federal government and some by the states themselves, has already begun to show some variations. Obamacare is off to a speedy start in Kentucky, for example, where the state runs it own exchange. Just next door in Tennessee, however, where the federal government is running the exchange and state lawmakers have fought Obamacare's implementation, the first week has been more of a struggle.
It's still early in the process, so it's hard to tell how anything will pan out, but it's possible that persistent technical issues or the states' varying degrees of success at marketing their exchanges could lead to disparate results. If initial trends continue or worsen, will states like Tennessee and Georgia -- which stacked the cards against Obamacare before it launched -- look at Kentucky and wonder why they can't have the same thing, or will they simply look at their own situations and declare the entire law a failure?
7. How will companies handle the employer mandate when it takes effect?
Earlier this year, the Obama administration announced a one-year delay of the Obamacare provision that requires businesses with more than 50 full-time employees -- or the equivalent in part-time workers -- to provide health insurance benefits or face a fine. The mandate's delay has been a major point of contention across the political spectrum.
Republicans say the delay until 2015 is further proof that Obamacare is in disarray, and argue that the mandate will eventually force employers to lay off employees or cut hours to avoid it. Some on the left, including Comedy Central's Jon Stewart, have suggested the administration's move was unfair, and a sign that the White House is too friendly to businesses. Others pointed to reports showing the delay meant 500,000 Americans would lose out on health coverage they otherwise would have been offered next year.
Most companies are too small to be affected by the full-time employee cutoff, and almost all large ones already offer health insurance benefits and will continue to do so. But for the 10,000 or so employers who don't currently offer health insurance to their more than 50 full-time employees, the concerns are real. Some businesses have already begun downsizing their staffs or cutting hours, making full-time employees part-timers, often in an effort to reduce the costs of insuring them.
But employer-sponsored health insurance coverage had seen erosion for decades before Obamacare was signed into law. In fact, that trend was a primary reason for health care reform. And unlike in decades past, people who have their benefits cut or get laid off will now be able to turn to the Obamacare exchanges for health coverage.
Many experts have suggested that the employer mandate's overall damage to employment and hiring has been vastly overstated by Republicans. We'll know the effects better as we get closer to the mandate's actual implementation, but it's also important to consider that the cost of employee health benefits isn't the only factor that companies consider when hiring and firing or setting hours.
8. Are there substantial technical flaws?
The Obamacare exchange signup website, Healthcare.gov, was largely incapacitated by high traffic and various minor glitches over its first week in action. While it's fair to question why the administration, obviously aware that it would be under heavy scrutiny from the law's skeptics, didn't do more to avoid this embarrassment, the website's failure is not necessarily significant when it comes to judging the longterm viability of the law.
The White House has taken action to fix the key software and capacity problems that were exposed when 8.6 million unique visitors went to Healthcare.gov last week. Some of the broader issues with the site's underlying development are beginning to be resolved, though it remains to be seen how and when the glitches will be fully fixed. Would-be enrollees have until mid-December to sign up in order to get coverage beginning next year, meaning there's some time to make sure the system is running smoothly. But the success of the program could be contingent on that happening sooner rather than later.
9. How secure are the exchanges?
It's understandable to have concerns about any program that will, by nature, keep troves of sensitive information online.
As CBS News reported this month, personal information for many new customers will be routed from a federal datahub to the state-based exchanges, opening up the possibility of security breaches. Conservative critics have said this datahub will be a "hacker's dream," and others have warned of the potential for fraudsters to create phony Obamacare pages that could trick would-be customers into giving away their information.
Obamacare officials have pointed to a strong track record of keeping information secure from hackers, claiming the concerns are overblown. Slate also reported that the design of the exchange datahub will make it difficult for hackers to target.