No Quick Verdict on Obamacare

This column originally appeared in Politico on September 30. Dr. Altman’s future Politico columns will be posted on one day after publication.

October 1, the focus of great attention in the Obamacare wars, is finally here.

Today is the day open enrollment begins for the new health insurance marketplaces, where Americans can log on and sign up for coverage.

The media, opponents, and proponents have been gearing up for a big day — or, maybe, a big week — when they can make pronouncements about how well Obamacare is working. But all we will really know at this point is how well eligibility and enrollment systems are working initially, since actual coverage doesn’t begin until January 1. When they throw the switch today, do the lights shine brightly, flicker, or not come on at all? The media will jump on early glitches, but if they are addressed, the memory of them will fade.

It will take weeks, if not months or more, before anyone knows how many people are signing up for coverage. People might take a wait-and-see attitude before they sign up or just procrastinate. And if you are uninsured, bewildered by the debate about the Affordable Care Act (Act), and wondering whom to believe, it’s not crazy to wait just a little while to enroll, as long as you don’t wait too long and miss out on your coverage kicking in next year. We may not really have a good sense of how many people will show up for coverage and whether they feel the premiums they are paying (after tax credits) are a good deal or not until the open enrollment period ends in March 2014.

Plus, how many sign up and how they perceive the affordability of the premiums themselves is only half the story. In addition to premiums, people will face out-of-pocket costs when they seek health-care services. And there are the benefits that Obamacare requires all insurers to provide — the usual hospital care and doctor visits, plus maternity care, mental health, prescription drugs, and more.

We won’t know how they feel about their coverage overall until people begin to use health services. If you think about your own family you know that not everybody will go to the doctor or the hospital or purchase drugs right away. Only when people start to use care will they pay their up-front deductibles, which in some cases will run thousands of dollars for plans sold in the exchanges, or pay their other forms of costs-sharing for doctor visits and drugs, or get free preventive services under Obamacare. All this will probably take at least a year to shake out, and maybe longer.

The Congressional Budget Office has estimated that about 14 million more Americans will be insured in year one, primarily through the exchanges or the state Medicaid expansions, which the Supreme Court made a state option in its ruling on the ACA. People’s experiences with their coverage will vary widely, depending on their state Medicaid programs, the plans offered in the exchanges in their states, and the health-care delivery systems where they live. Some people will be in a state-run exchange and others in a federal exchange. Every state Medicaid program is different. With so much variation, it will be even harder to come to a quick summary judgment about how the law is working nationally. This same variation offers opportunities to learn what is working best and to make improvements in the law, assuming our polarized Congress can ever get its act together to agree on changes to the ACA.

Then, in year two, an additional six million people are expected to be insured. More states might also choose to expand Medicaid or run exchanges themselves. It should be easier to get a broad picture of how the law is working by then.

October 1 is a handy news hook for coverage of Obamacare as it moves from a political dogfight to a reality — a new phase for the law. But it is not a magic moment to make a judgment about the ACA. All sides will be spinning their version of the early implementation experience, but it will take longer to come to any kind of reasonable judgment about how the law is working and what its lessons are. And while the noise level will be highest in Washington, in the end it’s the American people who will decide whether they like what they are getting from Obamacare or not.

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