Maybe private employers are dropping health coverage. Maybe job growth since the downturn is primarily in industries filled with low-wage jobs offering no benefits. Politicians on the right will blame Obamacare. Those on the left will blame the nature of modern capitalism.
But from the healthcare system's perspective, it really doesn't matter. If we're going to achieve universal coverage, the exchanges are going to have to run faster than expected simply to keep us on track for reaching the 95%-plus levels of coverage achieved in Massachusetts. So on this crucial component of the law, give President Barack Obama a B.
The president fared worse on expanding Medicaid, which was supposed to cover half the uninsured. Half the states chose not to expand the entitlement program, including states like Texas and Florida, which hold huge pockets of near-poor uninsured—many of whom work for employers who don't provide coverage.
Militant rejection by Republican-run statehouses played the central role in this failure. But politics, as German Chancellor Otto von Bismarck (the inventor of universal social insurance) reminds us, is the art of the possible. And it requires the art of persuasion to achieve what is possible.
Did Obama lack the skills or was there never a chance in these states? Again, from the healthcare system's perspective, it really doesn't matter. The glass is half full and the tap—at least through November and conceivably well beyond—has run dry. Give the administration a C.
The delivery system reform side of the ledger has a similar mixed record. If total healthcare spending was the only metric that mattered, the results would be astounding. Spending growth hasn't exceeded the overall economy for four straight years.
Administration supporters say that is because the reforms in the ACA are starting to work. But that remains unclear. It could just as easily be the rise of high-deductible insurance plans.
Whether one looks at Pioneer accountable care organizations, the Medicare Shared Savings Program or the bundled-payment demonstration project, the results are mixed. Some providers achieved the savings goals of the programs; some performed more or less the same; and some missed the targets.
More significantly, those demonstration projects only touched a fraction of healthcare providers across the country. The vast majority of hospitals and physician practices are stuck in a fee-for-service system that still rewards the volume of services delivered, not the overall improvement in population health incentivized by fixed-payment models.
Moreover, if the CMS remains stuck in demonstration mode, the reforms will begin to have perverse effects. They will primarily attract strong performers who think they can do well while leaving laggards untouched by reform. And among those opting in to the reform projects, the greatest rewards will go to the weaker performers who make up the most ground. Any system that does not reward its strongest performers risks losing legitimacy.
The one area where the administration can claim real progress is in reducing 30-day hospital readmissions. After hovering around 19% for years, that rate ticked down a percentage point last year. The improvement coincided with the imposition of penalties for readmissions—proving that universal reward/penalty systems work best for accomplishing overall goals.
Add it all up and the best grade we can muster for the CMS' efforts at delivery system transformation is a C+. The agency's students show promise, but they haven't been pushed to tackle the hard subjects.
Follow Merrill Goozner on Twitter: @MHgoozner