Forget the smiley face the administration will put on the final numbers from the Affordable Care Act open-enrollment season that just ended. Sign-ups are lagging far behind original projections. And with the political and legal landscape littered with landmines, it's not going to get any easier.
According to the latest estimates, sign-ups on the exchanges should top 10 million when the final numbers are in. But when the ACA passed in 2010, the Congressional Budget Office expected 13 million to sign up by 2015 (which was reduced in its most recent projection to 12 million).
The Medicaid expansion also is lagging. Tennessee and Wyoming last week became the latest states with Republican governors to reject extending coverage to adults earning up to 138% of the poverty line. That leaves 22 states on the sidelines. Many of them are like Texas, with huge low-income, working populations that would benefit substantially from expanding the safety net program.
In 2010, the CBO expected 14 million more people would be covered by Medicaid because of the ACA. Now, the government bean counters project 11 million, and even that may be optimistic.
Political opposition to the law remains fierce across the country. It still doesn't poll well despite the president's improving popularity.
The U.S. Supreme Court next month will hear a challenge that could unravel the subsidies, which are key to making insurance affordable for low- to moderate-income Americans without employer-based coverage. Without those tax credits, the coverage expansion will end and probably reverse course.
So it is timely to remind ourselves why putting an end to the scourge that leaves one-seventh of the population without health insurance is so important—not just for the obvious social and moral reasons, but for the economic relief it will provide to nearly everyone else. Unfortunately, that is rarely part of the public discussion.
The single greatest testimonial to the efficacy of the ACA came last fall when a Gallup poll showed the rate of uninsured fell to 13.4% in 2014, down from 17.1% a year earlier. When people have insurance, the providers of their care don't go uncompensated and insurance companies don't have to raise rates on the privately insured to cover their costs.
Reducing the number of uninsured also reduces costs over the long run. The annual Commonwealth Fund survey released in mid-January found the number of adults delaying care had dropped to 66 million, or 36% of adults, in 2014, down from 75 million, or 41% of adults, at the time of the ACA's passage. When people get the healthcare they need in a timely manner, the overall cost of care drops because fewer people wait until their conditions worsen and care becomes much more expensive.
The same survey also found that the number of adults reporting difficulties in paying their medical bills dropped to 64 million from 73 million of all adults in 2010. The sharp rise in high-deductible plans, which encourage people to postpone non-emergency care because they have to pay first dollars out of their own pockets, hasn't translated into delayed care or increased hardship.
But these improvements receive almost no media play—unlike the arguments before the high court next month, which will be closely watched by millions of Americans who normally don't pay much attention. In April, the media will be filled with accounts of the millions of people who will be paying higher taxes because of the penalties attached to ignoring the law's individual mandate.
This year, the penalty is $95, or 1% of taxable income, whichever is greater. But for next year's tax filers, the penalty rises to $325, or 2% of income, whichever is greater. The rising tax penalty is the No. 1 reason why CBO expects the number of people covered through the exchanges to jump from current levels (10 million-plus) to 21 million in 2016.
Higher penalties may double enrollment. Or it may harden opposition among the holdouts who have not responded during the first two sign-up periods. Given the political tenor of the run-up to the 2016 elections, I'd bet on the latter.
The Obama administration needs to develop a strategy that communicates the benefits of universal coverage to the vast majority of the public who don't directly benefit from the insurance expansion. So far, it has only pointed to needy families who obtained coverage for the first time.
For the ACA to succeed, President Barack Obama must find a way to create an environment where everyone feels obligated to obtain health insurance. Right now, that doesn't exist.