p o l i t i c o
By DAVID NATHER
March 28, 2014
Time’s up, Obamacare. Ready for your grades?
After six months, the first enrollment season is coming to an end. So it’s time to take stock, with POLITICO’s report card that covers the highs and lows of the rollout.
If you’re a supporter of the law, you might be cringing right now — you know the areas where the grade is not going to be good. It’s pretty obvious that the Obama administration wasn’t ready for the launch, despite three and a half years to prepare. The political messaging hasn’t impressed anyone; Democrats are scampering away from what was supposed to be a legacy achievement. No one’s going to forget that notion that everyone could keep their plans.
But the critics will have to round out their picture of the law, too. The signups have now hit 6 million — a feat that seemed impossible in the worst days of the website failures — and the administration’s outreach efforts are better than they used to be. And although there are lots of complaints about the prices, some low-income customers seem to be genuinely happy with the rates and subsidies they’re getting.
It’s also important to judge the rollout against the political headwinds the law has faced. White House officials argue that the battles against Obamacare have been stronger and longer lasting than even the fights against breakthroughs like Social Security and civil rights laws. “There’s no other law that has had to overcome all the obstacles that have been thrown at this law by its opponents,” said White House health care adviser Phil Schiliro.
But this is also a program that will affect millions of Americans, and Republicans say it’s such a bad student it should repeat a grade. “For gross incompetence, the thing should be held back a year,” said Brendan Buck, a spokesman for House Speaker John Boehner. “The law is clearly not ready for prime time — not that it ever will be — and that’s why the House has voted to delay it.”
Here’s where Obamacare was a good student and where it needs to show more effort, based on the latest research and interviews with health care experts across the board:
Enrollment
At this point, it’s all about expectations — and after months of lowering the bar, the White House has finally cleared it.
Thanks to the fumbled launch and an unspectacular February, health care experts had been convinced that the total enrollment would be roughly five and a half million people. That turned around quickly once the enrollment websites became flooded with last-minute signups, as the White House had predicted.
And on Thursday, President Barack Obama had his best day in months when the total hit 6 million, earlier than even optimistic experts thought it would.
That’s not nothing. It’s a big recovery from October, and it’s enough to avoid a financial disaster for the insurers. It’s certainly enough to give Democrats the talking point they want against Republicans: “Do you really want to take health insurance away from millions of people?”
It’s just not the original 7 million goal, as declared by Health and Human Services Secretary Kathleen Sebelius, and Republicans won’t ever let the administration forget it. (There was even a time when CBO was predicting 8 million, right when the law passed.)
Keep in mind, too, that enrollment numbers will come down if people don’t pay their premiums — currently as many as 15 percent to 20 percent of those who have signed up haven’t paid up. Numbers could also tick up during the rest of the year, because people can sign up later in special cases like getting married or having a baby, just like they can with workplace insurance.
Those aren’t the only people getting coverage. Another 4.4 million people who visited the exchanges are eligible for Medicaid and the Children’s Health Insurance Program. More are signing up through state Medicaid agencies. But that may fall short of expectations, too — CBO predicted 8 million people in Medicaid in the first year.
So yes, the Obama administration needlessly lost almost two months because of an incompetent website — but the last-minute numbers show it has made up a lot of lost ground since then.
Grade: A-
Mix of customers
It’s not where it needs to be — yet.
To keep premiums stable, health plans need a good mix of healthy customers to help pay for the sicker ones. Until they actually start racking up medical bills, the best substitute we have is to look at the ages of the people who have signed up. And so far, they’ve trended older.
By the end of February, 25 percent of the health exchange customers were ages 18 through 34, and 69 percent of them were 35 or older. That varies from state to state, of course, but overall the exchanges have been underperforming in signing up young adults.
According to the Kaiser Family Foundation, the 18-to-34 adults make up 40 percent of the potential market for individual health insurance, while 54 percent are age 35 or older. That doesn’t mean the final mix has to line up exactly that way, but it’s not going to build confidence among insurers if the young adults don’t sign up in greater numbers.
Obama himself says the age mix is important. The enrollment is already big enough to keep premiums “stable,” but “the impact in terms of the program has always been based more on the mix of people who sign up,” Obama told WebMD earlier this month.
Still, there are mechanisms built into the law to help insurers who don’t get enough healthy people in the first three years — and health insurers knew that going in. “I don’t think plans got into this thinking everything was just going to work out in the first year,” said Mark McClellan, who ran the Medicare agency under President George W. Bush and presided over the start of the Medicare drug benefit.
And there could still be a big surge in the next few days as 20-something procrastinators finally sign up — there’s some evidence that it’s already happening outside the official health exchanges. But it would have to be pretty big to change the mix significantly. So for now, it, too, gets a “not bad but not great” grade.
Grade: B
Who’s actually new?
There’s still a pretty broad disagreement about how many uninsured people are getting covered, which is much of the point of the law. But there are signs of at least some progress.
Gallup surveys have now found the uninsured rate declining three months in a row. In the latest survey, released earlier this month, 15.9 percent of Americans were uninsured, down from 17.1 percent in the last quarter of 2013. Health care analysts were cautious about the first surveys, warning that it could be a one-time dip, but that becomes less likely with each survey that finds the same results.
The studies by McKinsey and Co. tell a different story. In a survey released earlier this month, more than seven out of 10 of Obamacare’s new customers had health insurance before, and just 27 percent were previously uninsured. That was up a bit from its January survey, when only 11 percent were previously uninsured.
None of those surveys tell us exactly what we need to know. McKinsey doesn’t include Medicaid, and Gallup doesn’t prove exactly why the uninsured rate dropped.
And since the Obama administration isn’t tracking the progress on the uninsured in real time, we’re probably going to have to wait a long time for more definitive numbers, however maddening that is.
Grade: Incomplete
Readiness
There’s no point in spending a lot of time on this one. Does anyone really believe the Obama administration was ready to launch the biggest program of Obama’s presidency on Oct. 1? Even the president doesn’t think that anymore.
The administration needed to prove that government can still do big things. As Obama said on the day he signed the Affordable Care Act into law in March 2010: “We are not a nation that does what’s easy … We are a nation that does what is hard. What is necessary. What is right.” The disastrous launch of the federal enrollment website gave the whole program a reputation of incompetence — and once a program has earned that kind of reputation, it’s just about impossible to shake it off completely.
Grade: F
Website repairs
Once it became clear how badly HealthCare.gov was built, the administration scrambled an all-out repair effort that, against the odds, helped the federal website make a remarkable recovery.
For customers, at least, the website became much more user-friendly by the end of November than just about anyone expected. The administration didn’t have to scrap the website after all, a prospect that even Obama reportedly considered. Now, just about anyone who wants to can actually sign up for health coverage. And so far, at least, it's holding up under the crush of last-minute traffic.
If that were the end of the story, the administration might get an A+ for the repair effort. But it’s impossible to ignore the fact that the “back end” of the website still isn’t built. Customers don’t see those sections — but insurers do. Those are the parts that handle the payment of Obamacare subsidies to the insurers, the compensation for health plans that draw too many sick people and the confirmation of each enrollment.
So there’s a lot of manual work being done to take care of all that. For example, one industry source says health insurers are having to use “glorified Excel spreadsheets” to request their subsidy payments.
It’s almost as if the Obama administration did a big extra credit project, raised its grade, and then blew off some homework. It gave the highest priority to the most important part: fixing the customer side. But was it really too much to ask that the whole website would be ready after three and a half years of lead time?
Grade: B-
Outreach
The administration had to make up for lost ground. It couldn’t do much outreach while the website was spitting out error messages; you can’t tell people to go sign up on a website that doesn’t work. But since then, Obama and his team have been stepping up their game — and getting more creative.
Obama’s comedic skills on “Between Two Ferns” achieved their goal — the show was the top source of referrals to HealthCare.gov on the day it came out. And it likely gave Obama some cool points with the young adult crowd (though he may have lost some the next day by meeting with Lance Bass, the singer who tweeted the wrong website name). Michelle Obama wrote a blog post to new mothers on TheBump.com, Joe Biden went on “The View,” and Valerie Jarrett and Denis McDonough have done radio call-ins.
But some of the most effective outreach efforts, according to local health officials and community leaders, have been the old-fashioned kind — sending high-ranking administration officials to visit key cities, and connecting advocates who can organize outreach events.
In Houston, for example, Sebelius visited several times, generating media coverage that boosted outreach efforts of local elected officials, according to Kathy Barton, a spokeswoman for the city’s health department. Labor Secretary Thomas Perez has stopped by to pitch the health care law as well in a city with an unusually high uninsurance rate.
In Jacksonville, Fla., pastor John Allen Newman, who preaches at The Sanctuary at Mount Calvary, says White House officials put him in touch with Enroll America, the coalition of outside groups doing outreach and education. They visited the church several times with promotional materials and helped organize a health fair to spread information about the law.
“Certainly I was pleased with the response I got from the White House,” said Newman, who said the law is going to be “a godsend for so many in the African-American community” dealing with pre-existing conditions, like diabetes and high blood pressure.
So even if they got a late start, Obama and his team get high marks for their much improved, end-game outreach efforts — with just a few points knocked off for that Lance Bass thing.
Grade: A-
Messaging
Let’s be honest: No one’s blown away with the messaging on the biggest domestic achievement of Obama’s presidency.
Not Democrats in Congress, who are still doing research to figure out what the right message is. Not Hillary Clinton, who’s one of the law’s biggest supporters but noted earlier this month that “we have to do a better job than has been done, quite frankly, in explaining the benefits.”
And not Newman, the Jacksonville pastor, who says he has told White House officials that they’ve lost control of the narrative.
“I told them, I think that the battle was so hard-fought that you figured everyone would be so happy for the victory that you didn’t have to explain it. But Politics 101 is that you create the narrative,” Newman said. “They let the opposition create the narrative. And then they had to come out and say, ‘No, it’s not that.’”
It’s always easy to knock the White House and Democratic leaders for not messaging better, and a strong final enrollment surge could give them better material to work with. Obama is trying harder — he gave the health care law a full-throated shout-out in the State of the Union address this year. And polls show the law is recovering a bit from the damage it suffered during the early rollout.
But when you pass a law to help the uninsured, and the uninsured don’t like it — 45 percent have an unfavorable view of the law, according to this month’s Kaiser Family Foundation tracking poll — no one’s going to call that a messaging success.
Grade: C
Is it affordable?
This one is probably the broadest question of the launch: Is the Affordable Care Act coverage affordable?
It’s important to try to answer that question, but the answer depends so much on people’s circumstances and their expectations of health insurance, and even the state they live in, that it’s impossible to give one overall grade.
If you’re in the target group for the law, with a relatively low income or pre-existing conditions, or both, chances are you’ll find something you can live with — and you might get a very good price if you qualify for subsidies.
If you’re not in the target group, and you were happy with your old individual or small business health insurance, the odds are good that you’re running into sticker shock. That’s not going to happen to people who are keeping the insurance they get from a large employer or a public program like Medicare.
“The sticker shock question depends entirely on where you’re coming from,” said Dan Mendelson of the consulting firm Avalere Health. If you’re used to paying full cost and now you’re getting a subsidy, he said, “you have reverse sticker shock. If you’re young and healthy and you were in a low-cost plan, you’re having sticker shock.”
In general, Mendelson said, the premiums have been lower than expected, but the deductibles and out-of-pocket costs have been higher.
For an upcoming state-by-state study on exchange health plans, Breakaway Policy Strategies, a research and consulting firm, found that the average monthly premium in a “silver” plan — the second-cheapest and most popular kind — is $264.91 for a 27-year-old and $443.48 for a 50-year-old, not counting any subsidy.
If customers go one step lower, and buy “bronze,” they’ll find that the average premium is $229.97 a month for a 27-year-old and $385.20 for a 50-year-old. (There are also “gold” and “platinum” plans, depending on how much of your health costs you want to be covered.)
But if they get subsidies, the picture changes dramatically. In El Paso, people who have signed up for private health coverage at Centro San Vicente, a community health center, have gotten premiums as low as $25 to $50 a month after the tax credits are factored in, according to Jose Luna, the center’s chief executive officer. He said his future daughter-in-law, a college graduate, will pay $25 a month for HMO coverage from Blue Cross Blue Shield.
“Every single person I saw was ecstatic, with an exclamation point,” said Luna. “It is the subsidy that makes the insurance so affordable for the population we serve — and I’d even say for the majority of Texans.”
Consumer advocates say they’re not too surprised at the high deductibles, but they’re not satisfied with the sticker price of the premiums.
“Premiums aren’t where I want them to be. They should be lower,” said Lynn Quincy of Consumers Union. She doesn’t blame the health care law for that — she says the main culprit is doctors and other medical providers who overcharge.
Jamie Court, president of the California-based Consumer Watchdog, blames insurers themselves for not doing enough to keep their rates down, and would like stronger state regulation. Obamacare’s problem, he said, is that it “told insurers they had a guaranteed market and didn’t put a lid on how much they could charge.”
And there’s going to be more turmoil as small businesses upgrade their health coverage — with some paying higher premiums, due to the coverage requirements or new rating rules. “It’s a real nightmare,” said Michael Frasco, the chief financial officer of Montclair Art Museum in New Jersey, who says the premiums for his older employees are about to jump anywhere from 18 percent to 43 percent because of the complicated way premiums are calculated.
So is the Affordable Care Act affordable? It is for some people, but certainly not for everyone. That means the law needs two grades, one for the target groups and one for the spillover effects.
Grades:
For low-income and pre-existing conditions: A
For others who are affected: C
Did it help more people than it hurt?
If the launch of Obamacare had helped its target audience and left everyone else alone — or, at least, clearly helped more people than it hurt — it would have been a lot harder for the opponents to find ammunition.
But there are warning signs for Democrats in recent polls: The losers — or, at least, people who believe they are losers — appear to outnumber the winners.
The Kaiser Family Foundation poll found that 29 percent said they had been negatively affected by the law in February, while just 17 percent said they’ve been helped.
And a Gallup poll this month found that 10 percent of Americans said the law has helped them, while 23 percent said it has hurt them. In both polls, the majority said they haven’t been affected one way or another.
Is that solid proof that all of those people were really hurt? Not necessarily, but it is their perception. If all of those numbers were real, you’d have to believe that Obamacare just happens to single out Republicans — since 39 percent of them said they were hurt — and leave Democrats alone, since only 7 percent of Democrats reported that it had hurt them.
But perceptions matter in politics — and that’s why it spells trouble for the Obama administration that more Americans don’t believe they’ve been helped.
White House officials say those aren’t the only ways to measure who’s been helped. They argue that there are other kinds of help that can’t be measured by polls, like the end of lifetime benefit limits, free preventive services, the 3 million young adults who have been able to stay on their parents’ health plans, and the 7 million seniors who have saved on their Medicare prescription drug bills.
Given how much misinformation there is out there after four years, it’s possible that people are getting those benefits and aren’t aware of them, so it’s a good idea to be cautious about the poll results. And the public’s perceptions could change as people get more used to the law, and have a better awareness of what it does and what it doesn’t do.
But sooner or later, the Obama administration needs a real turnaround — because it’s not going to do it any good if the beneficiaries are outnumbered by people who think the law is hurting them.
Grade: B
If you like what you have, you can keep it
This one doesn’t need much discussion either. It’s the Republicans’ favorite talking point, that people with individual insurance didn’t all get to keep their plans. But “if you like your plan” is not just a talking point. It’s the standard Obama himself set, many times.
And as much as the administration tries to make that situation right — by allowing insurance companies to voluntarily extend the old plans, and giving them more wiggle room to update the old plans without canceling them — Obama will never be able to completely undo the damage.
Grade: F
Did the canceled-plans people ever get covered?
For all of the other problems with the rollout, it’s worth mentioning one bomb that didn’t go off: There never was a screaming army of people who had their health plans canceled and ended up uninsured.
Right up through the final weeks of December, that was a real possibility. The administration scrambled to make accommodations for as many as half a million people who hadn’t been able to replace their canceled policies — doing everything from pushing back enrollment deadlines to letting those people buy catastrophic health plans that were really supposed to be a backstop only for the young and healthy. If they didn’t have new coverage in place by Jan. 1, the worst-case scenario was a new wave of horror stories about people who actually ended up uninsured because of Obamacare.
And yet, after Jan. 1 came and went, there was mostly silence.
Did they all find coverage? Health care experts say it’s impossible to know for sure — mainly because there are so many ways they could have replaced it. They could have gotten it through the Obamacare health exchanges, but no one would know, because there’s no place on the application to mark down that they were a “canceled-plans person.” Or they could have gotten it directly from an insurer and never dealt with the exchanges at all. Some may have been able to extend their old plans.
It’s certainly possible that not all of them got covered, and that terrible stories could still emerge. But the fact that there was no big eruption of horror stories is significant. It’s possible that many of the people found other coverage with no help from the administration, but the odds are that its last-minute actions had at least some role in avoiding disaster.
Grade: A-
