The Status of Health Care Reform

When the health insurance exchanges required under the health reform law opened last fall with a massive thud, we suggested that those technical difficulties would be remedied but the deeper flaws of the law would be the source of long-run problems.  While a number of the exchanges are still struggling, and they don’t have all the functionality they are supposed to, they worked well enough to supposedly enroll around 7 million people.  As always in today’s world, caution must be exercised in approaching any numbers.  Out  of this seven million, apparently the majority, perhaps even the vast majority, already had some form of health insurance, so if the primary goal of the law was to reduce the uninsured population, it has not yet done much to achieve that goal through private insurance.  Apparently about 3 million people also have newly enrolled for Medicaid, and more of these people may have been uninsured.  What is clear is that the overall number of uninsured persons has been only modestly reduced to date.  Fooling no one, the Administration for obvious political reasons, has deferred implementation of major parts of the law, including the employer mandate.  It has also made the individual mandate very weak and enforcement realistically will be non-existent.  All of this further weakens the impact of reform on reducing the number of uninsured persons.  We may have seen the high point of that impact.

Millions of individuals’ insurance coverage has been impacted, generally in ways they do not perceive as positive.  In general, people are paying more, both in premiums and in   deductibles and copayments, and have less choice of providers.  People are more anxious about their coverage.  Already we are getting the early warnings from insurers that we can expect double-digit premium increases for the next year of coverage.  This may be due to a riskier pool of new members than the health plans anticipated when they calculated premiums for the first year, or it may be related to the apparent surge in health care costs and spending which occurred toward the end of last year.  While health care inflation and spending has been muted for several years, most experts have been anxious about its revival.  It may also be that insurers noted that there is relatively little competition on most of the exchanges, so enrollees don’t have much choice.  Whatever the cause, the Administration claims that health care coverage costs would be reduced under reform have been very plainly revealed to be outright lies.  Taxpayers should be anxious as well, as it appears likely that the cost of the Medicaid expansion and subsidies for those individuals who did enroll on the exchanges will likely be higher that projected.  So, all in all, really every indication that this will be another roaringly successful government program.

The big question everyone should be asking now is whether it really was ever necessary or important, much less fair, to force tens of millions of young and healthy people to buy health insurance.  There is absolutely no reason to do so from a public health perspective, it was solely an ideological choice to force a subsidization of the health care costs of older and less healthy persons.  Not clear to me why that is good public policy, when most of this spending is due to the behavior of the persons who are incurring it.