President Obama recently stated, "The Affordable Care Act is working ... The repeal debate is and should be over." Senate Minority Leader Mitch McConnell, one of the law's most vocal opponents, has maintained that the ACA "is beyond fixing. It needs to be pulled out root and branch, and we need to start over."
So which is it?
By a number of measures, the ACA is succeeding in its main purpose: reducing the number of uninsured and making sure that Americans have comprehensive, affordable health insurance.
• According to a recent Gallup survey, the number of uninsured Americans dropped from high of 18 percent in 2013 to a low of 14.5 percent at the end of March. For states that have set up their own insurance marketplaces and expanded Medicaid, the number of uninsured has dropped even lower -- to 13.6 percent. Those numbers will continue to decrease later in the year, with the next open-enrollment period and with more people signing up for Medicaid under the ACA's expansion provisions.
• According to Rand Corp., 9.3 million people gained health insurance coverage between September 2013 and mid-March 2014. About a third of the 3.9 million people that gained coverage through the individual insurance market were previously uninsured.
• Medicaid enrollment increased by 5.9 million, and the majority of these Americans did not have insurance before signing up.
• The non-partisan Congressional Budget Office estimates that 19 million people will gain coverage through the ACA by 2015, increasing to 25 million by 2016.
All of this looks like real evidence that the 25-year trend of increasing uninsured rates has finally been turned around.
It also appears that federal and state insurance marketplaces, or exchanges, in spite of troubled rollouts, are exceeding initial enrollment estimates and are becoming more attractive to insurance companies.
• More than 8 million people have enrolled through insurance exchanges.
• Thirty-five percent of those enrollees were under age 35. More important, 28 percent of enrollees were between 18 and 35. While this number is lower than hoped for, it may well be enough to prevent premium increases resulting from an age-skewed risk pool, the so-called premium "death spiral."
• Many insurance companies are seeing positive trends in the new marketplaces, including market size and higher-than-anticipated sales of mid-level insurance plans. United Healthcare Group, the nation's largest insurer, which offered coverage only in five public marketplaces this year, is now considering entering into more exchanges in 2015.
It's not entirely clear what effect these new enrollees will have on premium prices. Since insurance companies can no longer discriminate against people with pre-existing conditions, it will take some time for them to determine whether these newly enrolled policyholders are disproportionately less healthy. The higher the number of claims, the more likely it is that premiums will increase. While it is true that the more chronically ill were likely to be the first to enroll, there is realistic evidence that younger and healthier people were signing up in large numbers as enrollment came to a close. Based upon that and other reasons, the CBO has reduced its estimates for premium growth in 2015.
There are some other positive trends, as well. The number of people getting insurance through their employers increased by 8.2 million, largely due to an increase in employment. Contrary to numerous reports, fewer than 1 million people lost their private plans in the individual insurance market.
While it will clearly take more time to judge the real success of the Affordable Care Act, many of these initial measures are pointing in the right direction. And that might put into question whether repealing the law and reversing these trends is an especially good idea.
There is a flip side to the success of the Affordable Care Act, however, and that is the millions of Americans left behind -- those who did not gain access to health insurance and affordable health care.
In that sense, the ACA has highlighted an obvious division in the United States, made up of states that seem to be partitioned into two camps. The divide appears to be based largely on partisanship and two approaches to governing.
Some states expanded Medicaid to near-poor residents, as allowed under the ACA, and some did not. Some states embraced the law and created their own health insurances exchanges. Other states have not done all they can to fully implement the law, and some have even gone so far as to impose regulatory and legislative roadblocks.
As a result, the success of the ACA and access to insurance and health care may largely depend upon the state a person lives in.
Perhaps the largest measure of failure is that 24 states have not yet expanded Medicaid, including 21 that have refused to do so. According to the Kaiser Family Foundation, this has resulted in a coverage gap of 5.2 million Americans that will remain uninsured. Texas alone accounts for 20 percent of those uninsured Americans. The cost of emergency care for the uninsured will ultimately be passed on to residents in those states that have private insurance. And the downsides of this decision are not restricted to state residents. At least five public hospitals in Georgia, North Carolina and Virginia have reported cutting staff and services as a direct result of their state's decision not to implement the expansions.
The final report card on the ACA will come in years and not in weeks or months. But if we add these early results together, it seems clear that the ACA righted itself after a troubled launch, is attracting insurance companies into the new marketplaces, is improving competition between those carriers and is helping millions of Americans gain affordable insurance coverage. If those who want to repeal the law have their way, those same Americans may lose their new benefits and those positive initial results may be reversed.
But for now the law remains in place, and the divide may grow even wider. Residents and health providers in some states will reap the benefits of the law while others will not. Whether the motivations for the divide result from a political strategy or an honest disagreement over the role of government, the consequences are very real.
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