Today’s the day. As of midnight, if you’ve not enrolled in a health insurance plan under the Affordable Care Act (or asked for a special extension), you’ll have to wait until 2015 to buy coverage on the law’s exchanges. Medicaid enrollment continues all year.
The Obama administration has already declared the tumultous enrollment process of the past six months a success. After the rocky start of healthcare.gov, the Congressional Budget Office estimated 6 million people would enroll in private plans this year. Last week, the White House announced it had hit that number. That’s an important political victory for the administration, to be sure. But health policy wonks across the ideological spectrum agree the number doesn’t say much useful about the overall effort to fix our health care system. It doesn’t answer any of at least three crucial questions.
1) Is the law fixing the huge racial disparity in the insurance market?
“What we do know is that many millons of previously uninsured folk have now got health insurance,” says Brian Smedley, who directs health policy research for the Joint Center for Political and Economic Studies. “What we don’t know, however, is whether people of color are getting enrolled proportionate to their eligibilty in the population.” People of color make up more than half of the 47 million uninsured residents of the United States. By definition, any effort to meaningfully reduce the number of people without coverage will have to target those individuals. But there’s no data—at least, not yet—to tell us whether that has happened.
Nor do we know how the enrollment effort has worked when considering language access. In California—which has a state-run exchange that’s been among the most successful in signing people up—data shows that Latinos have lagged behind. Is that owing to language-translation challenges that many watchdogs have flagged nationally? And Smedley stresses those challenges affect more than Spanish speakers. Early on in the enrollment process, a coalition of Asian American community groups sent a letter to federal health officials flagging problems, such as a laughably confusing Tagalog translation of “deductible” in enrollment documents. The translation was literal and thereby led people to believe the term meant a reduction in their costs, rather than the amount they have to pay before insurance kicks in. Have these kinds of issues been resolved nationally?
“This is an area where so far it appears that much much more needs to be done,” says Smedley.
2) How is the law impacting local insurance markets?
Similarly, niether the big number of 6 million enrolled nor the statewide numbers that have been released thus far tell us much about how the insurance market has changed at the hyper-local level where it matters most. Take a state like New Jersey, where I’ve been following the law’s rollout. Poeple could be signing up readily in a relatively well-off area, but if there’s no movement on Newark’s roughly 70,000 uninsured residents—many of whom are working-poor individuals, who have proven hard to reach—the state’s health care system will remain broken. It also will mean the cost of coverage in Newark won’t go down, even if it does in other parts of the state, because insurance markets are local ones.
3) If the law succeeds in expanding coverage, will those people actually get care?
The runaway hit of the Affordable Care Act is Medicaid’s expansion. In the states that have accepted the expansion, enrollment appears to be going smashingly. (Notably, though, two-thirds of the 17 states with the highest uninsurance rates are refusing to participate.) But the unanswered question about Medicaid is will the already hobbled system be able to absorb all the new patients. These are by definition people who have been living and working just above the poverty line, in some cases for years, and likely have many complex health challenges. “Even for folk who are newly gaining coveage,” says Smedley, “where will they get their care?” Already, cities around the country struggle with a dearth of providers who accept Medicaid, because the program pays providers poorly, while other communities are top-heavy with high-end boutique providers. “We have such a terrible imbalance of community resources relative to community needs.” That challenge is sure to worsen if the law succeeds in bringing millions of working poor into the system.