No, it doesn’t. To the contrary, it’s kind of incredible how badly those initial Republican prophecies of doom have aged. On its key objective — reducing the rate of uninsured Americans — Obamacare has been a clear success. Whereas 18.2 percent of non-elderly Americans lacked health coverage in 2010, only 9.2 percent were without it in the first three months of 2023, according to U.S. government survey data. The Biden administration announced last month that a record 21 million Americans have enrolled in health-care insurance plans through Obamacare’s marketplaces. Government subsidies ensure that none of these enrollees pay more than 8.5 percent of their household income for a decent health plan; many qualify for plans at low or no cost to themselves. The premium volatility that defined Obamacare’s early years has settled. Meanwhile, the law’s expansion of eligibility for Medicaid has covered millions more people.
And the law has reshaped Americans’ expectations about their health-care system, enabling young adults to stay on their parents’ health plans up to age 26, providing coverage for people with preexisting conditions and reducing the risk that leaving a big employer means losing health insurance. By cutting “job lock,” it has the long-term potential to boost entrepreneurship and risk-taking.
Granted, getting here was hard. Marketplace premiums initially bounced around. HealthCare.gov, the federal portal for Americans to buy Obamacare insurance plans, was at first nonfunctional. A 2012 Supreme Court ruling enabled states to choose whether to expand Medicaid within their borders, and 10 still have not done so, leaving many people in those states without coverage.
But those who counseled patience, arguing that the most ambitious health-care reform in a generation would eventually succeed, turned out to be right. Obamacare, which polled badly in its early years, in part due to partisan GOP condemnation, has become quite popular: 59 percent of adults favor it, according the most recent data.
Still, risks lie ahead. Even if a reelected Mr. Trump were to try and fail at repealing and replacing Obamacare, as he did during his presidency, a second Trump administration could still undermine the law by executive action — as he also did while in the White House. Perhaps more important, leaving the status quo intact could result in disruption, no matter who wins the 2024 election. The federal subsidies that help Americans afford Obamacare marketplace plans are set to partially expire in 2025. Without them, many people — particularly those in their 50s and 60s, whom insurers may still charge more for coverage — would see their costs spike. Some would risk going uninsured rather than pay higher premiums.
Meanwhile, some 2 million Americans fall into the “Medicaid coverage gap” in states that still refuse to expand Medicaid. A quirk in the Affordable Care Act denies them federal subsidies to buy private insurance on Obamacare marketplaces. Most of these are working, low-income people — cashiers, cooks, waiters, house cleaners and janitors, according to KFF, a nonprofit organization that researches health-care issues. States gain nothing from holding out on this vulnerable group; KFF projects that non-expansion states could actually realize fiscal benefits from expanding Medicaid to cover them, because doing so would bring a large influx of federal money.
As experience continues to show what a mistake it has been not to expand Medicaid, pressure could mount on Republican state leaders who still refuse to do it. But it might fall on Congress to finish the job, by boosting the incentives for holdout states, or by helping affected people buy private plans. While lawmakers are at it, they should address the most significant area in which the law has fallen short: controlling high national health-care spending. The law’s drafters included measures to cut the national health tab, such as a tax on high-value “Cadillac” health-care plans. Congress eliminated the Cadillac tax years after the law passed. At a time of high national deficits, and in a country in which the health sector accounts for more than 17 percent of gross domestic product, Congress should reconsider — indeed, expand on — Obamacare’s full promise.
These continuing challenges should not obscure the big picture, though. For all the haranguing, hyperbole and hand-wringing, Obamacare is a policy success.
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