Open enrollment on the Affordable Care Act insurance exchanges starts in less than two weeks. Coverage expansion supporters are worried about whether the exchanges will succeed in luring a large number of new enrollees for 2016.
Despite the law's partial successes, there is lingering uncertainty about its effectiveness in establishing affordable, universal healthcare and about its political future heading into the 2016 elections.
More than 32 million Americans are still uninsured. It's estimated that 10.5 million of those people are eligible for subsidized exchange coverage and that millions more are eligible for Medicaid.
The Congressional Budget Office projected 21 million people would be enrolled in exchange plans in 2016, up from 9.9 million as of June 30. No one expects the Obama administration to meet that target.
The federal and state insurance exchanges are straining to hold on to customers who have already signed up. That's likely due to affordability issues, complex documentation requirements and confusion over plans' narrow provider networks. The Obama administration is promising major changes on the HealthCare.gov website to make it easier for consumers to predict their healthcare costs and find plans that include their providers.
Meanwhile, there are growing doubts about the consumer-driven healthcare paradigm on which the law is based. Studies show that even many insured Americans are struggling to afford needed care, given the growing deductibles and coinsurance costs they're facing in individual and employer health plans.
A new study published by the National Bureau of Economic Research found that workers at a large self-funded employer sharply reduced their healthcare utilization when their company switched in 2013 from a zero-deductible plan to one with a $3,750 deductible plus a health savings account. The sickest workers were the ones most likely to reduce their healthcare usage.
“We find no evidence of consumers learning to price-shop,” the authors wrote. “Consumers reduce quantities … including potentially valuable (preventive services).”
Republican and Democratic presidential candidates differ sharply on how they would remedy the shortcomings of the reformed U.S. healthcare system. The GOP contenders vow to repeal the ACA and replace it with a cheaper, less-regulated model. Last week, Jeb Bush released a proposal that would offer less-generous premium subsidies than the ACA, deregulate health insurance, and encourage bare-bones catastrophic health plans and health savings accounts.
Such proposals would not provide relief to consumers from high out-of-pocket costs.
In contrast, Democratic candidates Hillary Rodham Clinton and Bernie Sanders promise to broaden coverage and benefits. But even they disagree on how to do this, with Clinton proposing to reform the law by limiting consumers' out-of-pocket costs, and Sanders favoring a shift to a Medicare-for-all, single-payer system. Either approach would boost federal healthcare spending, making them nonstarters in Congress.
The continuing dissatisfaction with the ACA even among Democrats was illustrated by Sanders' comment during last week's Democratic presidential debate that, “We should not be the only major country on Earth that does not guarantee healthcare to all of our people as a right of citizenship.” Similarly, last month Clinton's campaign issued a statement that “for too many, their out-of-pocket medical costs are growing much faster than their wages.”
The coming weeks may offer a signal from voters about their mood on healthcare. There are state elections in Kentucky and Virginia, plus a single-payer ballot initiative signature drive in Colorado.
In Kentucky, a Democrat who promises to protect his state's Obamacare reforms—which have helped cut the state's uninsured rate in half—is in a tight gubernatorial race against a Republican who wants to roll back those changes. In Virginia, Democrats hope to win control of the state Senate, potentially enabling Democratic Gov. Terry McAuliffe to push through Medicaid expansion to up to 400,000 low-income adults. In Colorado, supporters have until Oct. 23 to gather 98,492 signatures to put a single-payer referendum on the ballot next year.
The outcomes in these states could send a message about how the public wants to address the many remaining imperfections in the U.S. healthcare system.