Having failed to beat the Affordable Care Act in Congress, in the courts, or at the ballot box last November, conservative opponents have one last chance to beat it on the field of reality. Republicans see the delayed implementation of the law’s poorly designed employer responsibility provisions as a sign that the law is fundamentally unworkable and will unravel, as long as conservatives keep up the fight. The White House, not surprisingly, disagrees. At a briefing I attended last week, senior administration officials painted an upbeat view of the implementation process and expressed eagerness to shift the focus off the political controversy and onto how the law will have concrete impacts on citizens’ lives.
In the short term, I doubt they’ll get their wish. Putting something as big as Obamacare into practice is bound to hit snags. Between conservatives keen to exaggerate problems for political gain, liberals keen to highlight shortcomings in order to make sure people get help, and journalists who know conflict is a better story than people being happy, the year ahead should still be full of rancor and negative press. But in a larger sense, I think the administration has this right. It’s forgotten today, but the launch of Medicare in the mid-1960s was full of hand-wringing about implementation. So was the addition of a prescription drug benefit a decade ago. The Affordable Care Act has key features in common with those undertakings: It gives a lot of money to a lot of people, which means it can fall short of becoming perfect policy by a fair margin and still be popular and successful.
Starting in about three months, states will be launching marketplaces, aka exchanges, where the currently uninsured are expected to buy insurance. The key to making them work is ensuring that each state’s exchange includes a mix of young and healthy customers alongside older folks with more health care needs. If not enough young people join the exchanges, premiums will rise, which in turn will force more customers out and the program will fail. This feature of the program — that it only works if a large number of people sign up — means the first few months will be the crucial period in which Obamacare either collapses or achieves liftoff.
The people most in need of health care services will presumably be the most motivated to sign up expeditiously on their own. From a humanitarian viewpoint, that’s fantastic. From a program stability viewpoint, however, it’s a bit of a problem. The state officials running marketplaces — and the federal ones running the marketplaces in the large number of GOP-controlled states that have refused to set up their own marketplaces — face the challenge of enrolling enough young and healthy people to create balance. The Congressional Budget Office estimates that out of the approximately 20 percent of the population that’s currently uninsured or insured on the individual market, about 7 million people will sign up for an exchange plan in Obamacare’s first six months. The administration believes that in order to make the math work, out of that 7 million, about 2.7 million enrollees should come from the 18-to-30 age bracket.
To get the job done, they have essentially three arrows in their quiver: campaign-style demographic targeting, partnerships with people outside the formal federal health care apparatus, and substantial subsidies.