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 But as the White House and its allies declare victory, major
hurdles remain. And it will take years to determine whether the law
will accomplish its mission of creating stable insurance markets
that can help a significant number of America's nearly 50 million
uninsured gain health coverage, experts say.
Republicans are counting on that uncertainty to play into their
strategy for the midterm congressional elections in November. Their
plan: Draw on public dissatisfaction with the Patient Protection and
Affordable Care Act to help the GOP win control of the U.S. Senate
and retain the party's dominance in the House of Representatives.
"We're not really going to know whether it worked or not until the
third or fourth year. And of course, that's two elections down the
road," said Timothy Jost, a professor at the Washington and Lee
University School of Law in Lexington, Virginia.
"What I worry about is that we won't be able to figure out whether
it's worked or not until it's too late," he said.
Even before the first enrollment period comes to a close,
Republicans and some Democrats have separately proposed election
year changes that could appeal to voter concerns — and would leave
the law substantially altered.
Republican proposals would undermine Obamacare by making health
insurance optional and returning sick people to high-risk pools. A
handful of Senate Democrats last week also proposed some
Republican-sounding ideas that would allow insurance to be sold
across state lines, discontinue the employer mandate for many small
businesses and allow low-premium, high-deductible plans to be sold
in the marketplaces.
Families USA, an administration ally on healthcare reform, plans to
make its own public recommendations this week on how the enrollment
drive for 2015 might be improved. "Our recommendations will build
on the laudatory success of the first enrollment period," said Ron
Pollack, the group's executive director.
"PROOF OF CONCEPT"
So far, enrollment has been uneven. About half the states are
expanding Medicaid as the law intended, and interest in private
insurance lags in more than a dozen states where public leaders
oppose Obamacare or have failed to produce a working state-operated
marketplace. Consumer costs next year could vary widely, with
premiums likely to rise in the double-digit percentages in states
with lower enrollment.
"In most of the country, they've basically done a proof of concept:
It can work. It has not yet succeeded and won't succeed until you
know that most of the uninsured have been covered and the market's
stable, with reasonable growth in premiums," said Larry Levitt, a
health policy expert at the nonpartisan Kaiser Family Foundation.
The nonpartisan Congressional Budget Office estimates that 14
million people will obtain health coverage this year through the
private insurance marketplaces or the expansion of the Medicaid
program for the poor. However, coverage is not expected to hit its
peak of 37 million people until 2018, when the CBO forecasts 25
million people in the marketplaces and 12 million enrolled through
Medicaid or its sister health plan, the Children's Health Insurance
Program
Over the next year the administration plans to fully link its
enrollment website, HealthCare.gov, with the insurance industry for
sign-ups and payments. The administration still has no automated
systems for confirming enrollment data, distributing subsidies or
compensating insurers for unexpected losses.
There are signs of a last-minute enrollment surge by younger adults
for 2014 that could help keep the new online marketplaces viable for
insurers. Hospitals and doctor practices are also introducing
changes to the way they provide healthcare in line with the law.
"The Affordable Care Act is here to stay. It's the framework that
everybody in the healthcare industry is working within and
developing their strategic plans around," said Dr. Ezekiel Emanuel,
who was a top White House adviser on healthcare during the law's
development.
"Even the opposition, the Republicans, recognize the ACA is the law
of the land, and despite the rhetoric, actually accept it," he said.
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Many of the newly insured are ready to declare the law's benefits.
Barbara Doucet, 63, of Newnan, Georgia, says she can afford health
insurance for the first time in 14 years and no longer worries about
what might happen should she have an accident or become seriously
ill.
"I was scared constantly, absolutely terrified that something would
happen and what would I do. I didn't sleep really well for a long,
long, long, long time," Doucet, a waitress and reform advocate, told
Reuters in an interview arranged through Consumers Union, a public
advocacy group that sees Obamacare as a benefit to consumers. "I'm
extremely pleased with ACA, I really am," she said.
Stories like Doucet's clash with tales of people who find insurance
more expensive because of Obamacare's expanded coverage
requirements.
Amy Newbold, a 57-year-old saleswoman from Randolph County, North
Carolina, lost her employer insurance last year.
Through HealthCare.gov, she found a mid-tier "silver" plan with
premiums that at first blush are $75 a month lower than her previous
policy. But there are no savings, she says, since her old premiums
were paid with pretax dollars and Obamacare premiums are paid with
aftertax dollars. Newbold said she faces substantially higher drug
costs for arthritis and psoriasis and worries that an out-of-pocket
maximum of $5,000 could put needed medicines out of reach.
"I feel left out in the cold, and I don't know why it has to be that
way," she said in an interview arranged through the office of
Republican U.S. Representative Renee Ellmers, an Obamacare opponent
from North Carolina.
"IMPROVING" THE LAW
If Republicans seize the Senate from Democrats, Obama may be forced
to compromise on key aspects of the law, including requirements that
most individuals obtain coverage and that employers with 50 or more
workers offer health coverage, two of its most unpopular provisions.
Polls show most Americans would prefer to see Obamacare changed, not
repealed. In a March survey from the Kaiser Family Foundation, most
Americans dislike the law, but 59 percent wanted it retained or
improved.
That could make Republicans think twice about pushing for repeal.
But analysts say big changes may still be likely.
Some key features of the law are likely to endure, they say,
pointing to the ban on higher costs for people with preexisting
medical conditions and new medical business models that discourage
costly fee-for-service medicine by putting a priority on patient
outcomes and cost savings.
Analysts say Republicans could also scale back marketplace subsidies
to help low-income consumers buy insurance, pricing restrictions on
insurers and taxes intended to help fund the reform effort. And they
predict that if Democrats are chastened by losses in the
congressional elections, they might be more inclined to back some
Republican proposals.
"Republicans will make changes. It's not a question of 'if.' It's a
question of how many," said James Capretta, a health policy expert
with the conservative Ethics & Public Policy Center.
(Reporting by David Morgan; editing by Caren Bohan, Michele
Gershberg and Douglas Royalty)
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