Hillary, Trump, and the Success of Obamacare

Tonight, an anticipated audience of 100 million will all be tuned in to watch the first presidential debate between democratic nominee Hillary Clinton and republican nominee Donald Trump. A big part of the draw is the expectation of being entertained by a real estate developer turned brand curator turned reality TV star turned candidate for leader of the free world, who is undoubtedly entertaining. As has been stated repeatedly by many on both the left and the right, Donald Trump has said numerous things during his campaign that would have historically disqualified any other candidate. At the same time, there is a strong narrative that has circulated for decades that Hillary Clinton is not trustworthy–even when it can be independently verified that she is telling the truth. When it comes to politics, people are inherently irrational, but we seem to be taking that lack of thought to another level. The LA Times just reported that the “scope of Trump’s falsehoods [is] unprecedented for a modern presidential candidate.” Yet Clinton is the one with a website devoted to her called–and I am not making this up–LyingCrookedHillary.Com. And the articles emerging on Trump’s lying were all coordinated by the Clinton campaign, according to the folks behind a website appropriately titled “Hot Air.” Some have complained that the media is going too easy on Trump while the Trump campaign has called the media out for going too easy on Clinton. At the same time, both the Trump and Clinton campaigns have claimed the media is being too tough on them. But what about the facts? Although Trump has said that the media should not be engaged in fact-checking, there are many who are hoping that there will be real-time fact-checking at tonight’s debate, so that neither candidate is allowed to get away with lying to the American people. Fortunately, sources such as the Pulitzer Prize winning PolitiFact, and Bloomberg TV, will be doing just that.

Still, in advance of tonight’s debate, I feel compelled to engage in a little bit of preemptive fact-checking on a topic I care deeply about: U.S. healthcare. With only 90 minutes to debate, and with such vague topics as “America’s Direction” and “Achieving Prosperity,” it is unclear whether and to what extent healthcare will be discussed by either candidate. If the issue is raised, however, you can bet that Trump will do his best to throw Obamacare under the bus, while Clinton aims to defend it and stress the need to improve it. If you hate Obamacare, you’ll love what Trump says, and if you love Obamacare, you’ll love what Clinton says, but that’s still based on biases, emotion, and gut instinct. What about facts? Well, the facts are that only 9% of Americans are uninsured today–the lowest that number has been since it began being tracked. Obamacare has clearly succeeded in providing health insurance to approximately 20 million Americans. Still, that is just a single measure, and both opponents and proponents of Obamacare have other criticisms of the law. If only there were more facts.

Fortunately, thanks to the work of Molly Frean, Jonathan Gruber, and Benjamin Sommers, we know quite a bit about the success of Obamacare in providing insurance coverage. In last week’s New England Journal of Medicine the three co-authored a piece entitled “Disentangling the ACA’s Coverage Effects–Lessons for Policymakers” which outlines where the gains in insurance coverage occurred. They found that 63% of the gains in insurance coverage in 2014 were attributable to Medicaid, while 37% were attributable to private insurance purchased on the federally-subsidized Marketplace. Interestingly, the Medicaid expansion–in which 31 states and the District of Columbia are participating following the Supreme Court ruling that made it optional–is having an effect, but so too is the “woodwork” or “welcome mat” effect that results when policies cause previously eligible persons to enroll for the first time. Examples of these policy changes enacted by Obamacare might include the individual mandate to have insurance coverage, as well as the streamlined enrollment process through Healthcare.gov.

I reached out to Dr. Sommers, who is an Assistant Professor of Health Policy and Economics at Harvard’s T.H. Chan School of Public Health for his comments on the study, and this is what he had to say: “One of the key findings here is that despite all the recent attention on the Marketplaces in terms of premiums and several large insurers cutting back their presence, Medicaid remains the workhorse of the ACA’s coverage expansion.” Sommers is referring to the collapse of co-ops nationwide, the high-profile exit of insurers like Aetna, Humana, and UnitedHealthcare from the Marketplaces, and the proposed double-digit increases in health insurance premiums in many markets. It’s not that those issues aren’t cause for concern–they are–but it’s striking to see that Medicaid is accomplishing so much in its own right, even as just under half of states have not expanded the program.

“Another notable finding is that we found no evidence that the law was leading a loss of employer provided coverage, which had been one of the predictions offered by opponents of the law,” said Sommers. You might remember Congressional Republicans referring to the “Job-Killing Healthcare Law” during their numerous efforts to repeal Obamacare. The notion here was that larger employers who were mandated to provide insurance coverage to their employees might downsize their workforce to control their insurance costs. A related concern is what is known as “crowd out”–namely that when Uncle Sam offers subsidized insurance, many smaller employers–who were not mandated to provide coverage–would decide to stop offering insurance to their employees and let the government foot their share of the costs. Fortunately, that doesn’t appear to be happening.

Finally, according to Sommers, “We find that state policies have a big impact – not just the obvious question of Medicaid expansion, but also whether states started expanding Medicaid before 2014 (which led to bigger coverage gains) and whether they ran their own state Marketplaces (which made the premium subsidies more effective at enrolling people). It’s a federal law, but the states have a lot of discretion in how they implement it.” The fact is, Obamacare is working, but it works better in some states than others. More importantly, circling back to tonight’s debate and the presidential election, the law is imperfect. The outcome of this election will have much to say about its fate. If Trump wins, it is unlikely that the law will be repealed, but it is likely that nothing will be done to improve it and build upon this early success, and there is reason to be concerned about the long-term stability of Obamacare with adverse developments in the health insurance Marketplaces. Conversely, if Clinton wins, the law will certainly not be repealed. The extent to which it is strengthened will depend upon control of both houses of Congress, and the degree of policymaking that can occur through the executive branch and its federal rulemaking process. The fact is that 20 million uninsured Americans have gained health insurance since 2010. That’s more than the entire population of New York or Florida. What happens going forward depends on you and your vote. So, watch the debate tonight, check the facts, and vote in November.

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