Breaking Through The Floor

Update: You’ve probably noticed that Wright on Health posts have been few and far between lately. The simple explanation is that academic life pre-tenure is time consuming–especially when you try to be attentive to other even more important things like being a husband and father–and writing a blog, as important and personally fulfilling as it is, doesn’t “count” towards my success in those areas. And I’m not paid to write this blog, so it necessarily takes a back seat to everything else. In fact, several times, I’ve considered hanging up the blog altogether. But I maintain hope that I will one day find the time to blog more regularly once again. At any rate, if you’re reading this, I thought you deserved an explanation for my absence, and I couldn’t just write you this update without an accompanying post, so here you go…..

Yesterday, the Congressional Budget Office released new projections on the number of Americans expected to sign up for health insurance through the ACA/Obamacare Marketplace in 2016. If you’re the kind of person who likes to see things for yourself, take a look at page 69 of this report. You have to go digging around in the footnotes, but there you’ll find that CBO originally projected 21 million Americans to purchase coverage through the Marketplace in 2016, a number they’ve now revised downward to just 13 million. As is being widely reported this morning from outlets like The Hill, that’s a 40% reduction. There are two ways you’re likely to respond to that information, assuming you pay it any mind at all.

The first is to think: “Wow. The government really got it wrong. They missed the mark on that one.” And that’s absolutely right. Now, how you spin that is a matter of your pre-existing political beliefs. If you’re more progressive, you’re probably inclined to discount that failure. “No one has a crystal ball,” you might say. “Of course their numbers are going to be off sometimes,” your buddy will chime in. Conversely, if you’re more conservative, you’ll jump to the obvious conclusion that this is simply more evidence of government ineptitude. “They can’t ever get anything right,” you might say. “Yeah, tell me about it. Thanks, Obama!” your buddy will reply sarcastically. While it might seem, given their diametrical opposition, that one of these perspectives must be true and the other false, let me suggest that other from the obvious fact that the CBO’s projection was off target, they’re both wrong in their interpretation of that.

The second, and I would submit more accurate, way to think about this is to dig a little deeper and ask what it truly means. Although they can be interpreted at will, the numbers don’t lie. The CBO estimate was off target. This mistaken projection should neither be written off by the progressive, nor given undo importance as evidence of government’s incompetence by the conservative. The truth is that, to the extent that Obamacare’s major goal was to reduce the number of uninsured Americans, it has been a success. The rate of uninsured Americans is the lowest it has ever been since we started tracking that data more than 50 years ago. At the same time, the country still has a long way to go if the goal is to ensure that every American has some form of health insurance coverage. In that respect, Obamacare has underperformed. The CBO projections have proven to be overly optimistic. The reduction in the number of uninsured seems to be leveling off. In short, we’re approaching a floor. Now, on the other side of that floor, there are people who qualify for benefits under the ACA as originally enacted. The question we face now is how to improve implementation and outreach efforts. First off, there are the 20 states that have still refused to expand their Medicaid programs, denying insurance coverage to their most vulnerable residents. Unfortunately, there’s not much the Obama administration can do about that. But then there are the Marketplaces and it’s imperative that we do more to make sure that people are knowledgeable about how they work, how to find out if they are eligible for subsidies, and how to get and keep coverage. An alarming number of people signed up for coverage and then never sent in their first premium payment, so their policies were never in force. There are certified application counselors and the like out there, but we also need to better understand the barriers people face in navigating our complex healthcare system. This is public policy and community outreach. This is health services research and implementation science. The point is, it’s going to take a real concerted and ongoing push from many fronts to break through the floor. Millions of Americans would benefit. It is up to us to help them.