Coverage Has Expanded—More Than Expected

The ACA expanded coverage by pursuing a “progressive federalism” strategy—states were given the option to participate but the federal government retained sticks, carrots, and backup alternatives—as Theda Skocpol and I argue. ^{Footnote 11} States had the option to establish health insurance exchanges that showcased private health plans and met basic standards; if they chose not to (as two-thirds did), the federal government created exchanges for their residents. To make the selection affordable, individuals with incomes at 100 percent of the federal poverty line (FPL) up to 400 percent of the FPL (family of four earning up to $95,400 in 2014) were entitled to subsidies in the form of tax credits. About three-quarters of Americans who signed up on the exchanges in 2014 received a subsidy, which averaged $4,410 according to the Congressional Budget Office (CBO). ^{Footnote 12}

The second prong of the ACA’s progressive federalist strategy was to give states the option of expanding Medicaid to include all individuals (including adults without children) below 138 percent of the FPL ($32,913 for a family of four); if they refused, states risked a substantial portion of their existing Medicaid funding. This was a substantial and significant nationalization of social welfare policy. Before the ACA, many states excluded desperately poor adults who lacked children—their earning had to drop below 25 percent of the FPL in Texas, Louisiana, and Alabama. The Supreme Court’s historic decision on the ACA in June 2012 upheld the law’s constitutionality but gutted its Medicaid stick; Washington was prohibited from withholding funding. Nonetheless, the ACA wielded powerful enticements—full payment of Medicaid’s new coverage for three years and generous support afterward.

Access has been dramatically widened by state and federal insurance exchanges and state expansion of Medicaid in about half of the states—including 12 states with a Republican governor or a conservative Republican legislature. Although precise figures are not final, the ACA has covered between 15 and 24 million people. The workhorses are the insurance exchanges, which attracted 8.1 million to sign up, and Medicaid and its companion program for children (Child Health Insurance Program), which covered an additional 4.8 million. ^{Footnote 13} Further gains have come from employer-sponsored health insurance plans (110,000 and possibly 8.2 million more) and the new coverage for youth up to 26 years of age who are included in their parent’s plans (1.60 to 3.1 million). ^{Footnote 14}

A growing number of studies using diverse methods are detecting a notable drop off in the rate of uninsurance, as the ACA was implemented. Gallup finds that the percentage of Americans who reported that they lacked coverage quickly fell from 18 percent in late 2013 to 15.9 percent by early 2014—its lowest rating since 2008. This decline is sharpest in states that expanded Medicaid. The Urban Institute reports that the ACA’s first open-enrollment period extended coverage to 5.4 million Americans 18 to 64 years of age who were previously uninsured—this represents a 2.7 percent decline in the country’s uninsurance rate. ^{Footnote 15}

Apocalyptic projections of 5 to 6 million joining the ranks of uninsured as a result of insurance policy cancellations are contradicted by emerging evidence. Some will lose coverage and face higher premiums but early estimates suggest that two-thirds will be eligible for tax credits and will find coverage. ^{Footnote 16}

The early pattern of rising enrollment and falling rates of uninsurance is now locking into place. The non-partisan CBO reports that 34 million will be covered by the exchanges and Medicaid/CHIP as Obama finishes his term, helping to bring coverage to 92 percent of American citizens and reduce the ranks of uninsured by 25 million people. ^{Footnote 17}

Of course, hurdles remain. After the first open-enrollment period, 28 percent of those signing up on the federal exchange are “young invincibles” (18 to 34 year olds); the administration’s target was 40 percent in order to widen protection and to balance the pool of insured with individuals who were, on average, healthier. This shortfall needs to be tracked but much-ballyhooed claims that it would spike premiums were overstated. The key factor is the mix of healthy people in the exchange insurance pool, not “young invincibles” alone. While premium increases will occur, their magnitude will be moderated by the stabilizing of insurance markets over time and by a series of mechanisms to spread the distribution of less-healthy individuals among insurers. ^{Footnote 18} Another ongoing challenge will be enrolling vulnerable populations—often in communities of color.

ACA Strategies to Tame Insurers

Prior to the ACA, American health insurance was a wild west. What made sense for society—covering the costs of being treated for illness—was bad business. The insurance business model was built, in part, to avoid the sick and their higher costs. Meanwhile, millions of Americans lacked insurance; unpaid medical bills became a leading cause of bankruptcies. ^{Footnote 19}

One of the ACA’s largest impacts is invisible to most Americans—new rules of the road to stop insurers from avoiding the ill or hitting them with exorbitant fees. Insurers are now prohibited from turning away individuals with preexisting medical conditions and charging them (or women) higher premiums. Insurers were also compelled by the “medical loss ratio” rule to invest 85 percent of premiums (80 percent in the market for small groups) to “clinical services” and “activities that improve health care quality,” facing penalties for excessive spending on administration, profits, and executive salaries.

The transformation of private insurance markets has been surprisingly smooth. The pricing of premiums has been more moderate than the CBO initially expected and the participation of private health plans has been more extensive than projected—a sign that the new market is working. In addition, policy mechanisms to reap more social benefit from private insurers are also having an impact. The “medical loss ratio” has compelled insurers to pay $1.6 billion to 8.5 million consumers in 2012 and nearly 13 million in 2011. Consumers saved an additional $3.4 billion as insurers cut back on administrative costs that had previously been passed on in premiums, according to the National Conference of State Legislatures.

The Political Economy of Health Care Costs

Health economists label expenditures on medical care as (excessive) “costs;” in fact, they are a register of the program benefits to high-turnout voting blocs and the profits and salaries of well-organized and affluent businesses and professions. Faced with the powerful confluence of private interest and political organization, health reformers in 2009 made a brazen promise to expand coverage to over 30 million Americans while simultaneously “bending the cost curve” downward. Their solutions navigated the shoals of existing political power without directly confronting them.

The rate of growth in health care expenditures would slow, reformers reasoned, in the wake of competition among insurers for customers on the new exchanges, the new “medical loss ratio,” and new rules and experiments for paying providers that shifted incentives from rewarding the volume of services to encouraging quality performance by penalizing hospitals for the readmission of patients or bundling payments for one diagnosis (such as a hip replacement) instead of paying for each identifiable service.

Reformers boasted a remarkable accomplishment by the end of 2013: health inflation, which had ranged from 16 percent per year in the 1980s to 9 percent range in the early twenty-first century, fell to 3 to 4 percent after the ACA’s passage—the slowest rate in 50 years. By 2014, the cautious CBO and other non-partisan government expert bodies reported that reduced health inflation would decrease the budgetary outlays for the ACA’s insurance coverage below previous estimates by $5 billion in 2014 and by $104 billion for the coming decade. ^{Footnote 20}

Reformers’ victory over health inflation, however, may be short-lived. As the economy strengthened after the Great Recession and the ACA started to cover millions, both the White House and independent researchers projected increased health spending. The Chairman of Obama’s Council of Economic Advisers, Jason Furman, warned in June 2014 of the inflationary pressure of rising demand: “it is likely that the coming quarters will see faster growth in total health care spending as the millions of people who gained health insurance coverage… begin to use their new coverage.” ^{Footnote 21} The White House’s warning was echoed by independent analysis that similarly anticipated an acceleration of health care spending because of increased demand both from consumers who had delayed care during the economic downturn and from the newly insured. ^{Footnote 22} As demand rises, control over pricing largely remains in the hands of pharmaceutical and medical device producers and hospitals. ^{Footnote 23} If health inflation rises, the ACA’s tweaks to existing subsidies and cautious deference to stakeholders may pose a challenging choice between anguished benefit cuts and directly challenging powerful private interests.

Making Access to Health Insurance a Social Right

One of the enduring comparative features of US social welfare policy is its selectivity and connection to employment in contrast to the tendency in Germany and, especially, North Europe toward universal social rights anchored in citizenship. ^{Footnote 25} The ACA departs from the liberal welfare state model by expanding medical coverage and declaring it a social right, loosening the dependence of individuals on private markets for economic security.

The ACA explicitly linked eligibility to the status of being “a citizen or national of the United States.” This explicit declaration was partly geared to bar undocumented workers but the structure and language of the ACA legislation is one of “rights.” Medical care is no longer distributed to the non-elderly as another commodity traded in private markets but is legally defined as owed to each citizen as a full and equal member of the community.

Tying medical coverage to citizenship (rather than markets and the ability to pay) required a new approach to financing—one that relied on redistribution from relatively affluent individuals, professions, and businesses. The ACA’s insurance subsidies, Medicaid expansion, and other benefits are financed by two taxes on individuals whose yearly income exceeds $200,000 or for married couples earning over $250,000—an increase in Medicare’s tax on earnings by 0.9 percent and a new 3.8 percent tax on capital gains from investments. ^{Footnote 26} These taxes fall on less than 2 percent of tax filers, according to the non-partisan Tax Policy Center. ^{Footnote 27} In addition, insurers, and medical device and pharmaceutical manufacturers pay new fees; hospitals face cuts. The CBO and the Joint Committee on Taxation (JCT) projects the ACA will raise $813 billion between 2012 and 2021; the tax bill is picked up by the most affluent 3 percent of households as well as prosperous medical industries and providers. ^{Footnote 28} President Obama’s efforts at comprehensive tax reform failed but the ACA stealthily enacted the most redistributive changes in decades—changes that were more progressive than the general tax reforms that the Obama administration did consider.

Even as health insurance and medical care were recast as social rights, the selectivity long associated with America’s liberal welfare state lingers. Workplace success continues to produce more generous health plans and ability to pay drives individual choice among health plans on the government insurance exchanges. ^{Footnote 29} In addition, the decisions (or inactions) of 24 states not to expand Medicaid has left about 5 million Americans in a “coverage gap;” these states denied them coverage because they were childless or earned too much to fall below miserly state eligibility levels but too little to qualify for subsidies to purchase insurance on the government exchanges. ^{Footnote 30}

Even as selectivity persists, the ACA pursued subterranean strategies to reduce its effects without alarming its staunchest ideological defenders. With little notice, nearly all states have accepted the ACA’s offer to pay 90 percent of the costs associated with modernizing Medicaid’s administration and streamlining its enrollment and eligibility infrastructure. Although data are not yet available, this “submerged” strategy is expected to sign up tens of thousands of people who were previously eligible but did not enroll for a number of reasons: they lacked adequate information, were discouraged (often intentionally) by complicated administrative processes, and faced an unresponsive state bureaucracy. Administratively streamlining enrollment largely eluded notice by Tea Party members and other reform opponents, facilitating its adoption in states (such as Texas and other conservative enclaves) that refused to implement the ACA. Reformers designed the “90/10” program and other low-salient programs that relied on targeted funding and tax subsidies as part of a gap-filling strategy that ducked a futile push for comprehensive universality while building expectations for access and coverage that could be mobilized in the future. ^{Footnote 31}

Widening the Boundaries of Public Decision Making

A striking characteristic of American politics is the comparatively restrained boundaries of the public sphere and the more encompassing parameters of the private. Some of the most visible public features of European social welfare—such as family and housing policy—are “silent” or “submerged” in the United States. ^{Footnote 32}

The ACA “publicizes” questions, social problems, and economic activities that have long been treated as “private.” Before 2010, for instance, communities of color experienced “excess mortality” (black men living in Harlem were less likely to reach the age of 65 than men in Bangladesh) and insurers routinely charged women higher premiums. Meanwhile, it was a private prerogative for commercial health plans to divert up to 30 percent of premium revenues to profits, CEO salaries, and administration. ^{Footnote 33}

Deploying government authority to regulate. After the ACA’s passage, private businesses (with more than fifty employees) no longer enjoyed the unencumbered prerogative to reach decisions about whether to offer health insurance to their workers and how generous to make policies. Government authority now mandates large employers to offer coverage or pay penalties for each full-time employee who instead turns to the government’s exchange and receives tax credits. ^{Footnote 34} Employer-provided “Cadillac insurance” (those with annual premiums more than $10,200 for an individual or $27,500 for a family) is also subject to new public scrutiny; beginning in 2018, generous plans are scheduled to be taxed, partially offsetting longstanding exemptions for employer coverage.

In addition, the ACA regulates who health insurers cover, the benefits they offer, and other aspects of coverage. Health insurers are now required to offer—free of charge—a range of preventive health services for women (mammograms, prenatal care, and screenings for cervical cancer), and they can no longer single out women for higher premiums. Moreover, the decisions of commercial insurers to raise premiums are more regularly subject to public review. In addition, the “medical loss ratio” rule is prodding insurers to reduce non-medical expenses and target more resources to health and medical care. ^{Footnote 35} In short, these and other ACA regulations are renegotiating longstanding private/public boundaries.

The battle to control costs. The ACA’s renegotiation of public/private boundaries faces a momentous test in its drive to control health care costs; containing costs collides with long established patterns of deference and with the high salaries and bottom lines of well-organized stake holders. At Medicare’s inception in the early 1960s, deference to the private decisions of medical providers prompted presidents John Kennedy and Lyndon Johnson to reject the recommendation of civil servants for “direct government control” over provider reimbursement in favor of allowing doctors and hospitals to determine their own charges after supplying care. Not surprisingly, Medicare costs rose rapidly. ^{Footnote 36}

Torn between controlling rising budget deficits and government activism, President Ronald Reagan deployed national government authority to initiate a prospective payment system that regulated Medicare’s reimbursement rates rather than allowing providers to set their own rates retrospectively. In particular, Reagan tied Medicare’s hospital reimbursement to a fee schedule for “diagnosis-related groups;” subsequent presidents would expand the prospective system to Medicare’s reimbursement of physicians and outpatient care. The result of rate setting for Medicare has, in general, been effective; its spending has risen more slowly per person than private insurers, which pay doctors and hospital 25 percent more. Recently, Medicare cost increases per person (0.5 percent in 2014) have even fallen below the very low general rate of inflation (1 to 2 percent in 2013 and 2014). ^{Footnote 37}

The ACA rejected, however, rate regulation (as showcased by Medicare) in favor of uncoordinated efforts and experiments that may prove ineffective, if health inflation accelerates as the Obama White House and independent analysts project. ^{Footnote 38} One of the ACA’s most significant cost savings was to gradually eliminate the elevated subsidies to private insurers in Medicare Advantage, which were on average 14 percent higher per person than traditional Medicare. ^{Footnote 39} Overstated warnings—fanned by insurers—that the subsidy reductions would undercut insurance for seniors in Medicare Advantage provoked widespread congressional protests and a retreat by the Obama administration from the planned payment cuts in 2014 and 2015. ^{Footnote 40}

The ACA also took aim at scaling back America’s “supply state” of using government payments and subsidies to support private insurers, medical providers, and employer-sponsored insurance (ESI). ^{Footnote 41} Reformers delayed and scaled back the proposals by Republicans and moderate Democrats to reduce tax exemptions for ESI during the ACA’s journey through Congress in 2009; the legislation signed into law in 2010 is scheduled to impose a new 40 percent excise tax on “Cadillac” insurance plans in 2018. But pressure is building to delay the tax further or to end it altogether—a scenario that appears to be gaining momentum in Washington.

The ACA’s reluctance to fundamentally disrupt private insurance and provider markets is epitomized by its revival of a slightly altered managed care model. Managed care organizations blossomed in the 1990s as a means to spur competition among insurers that contract with coordinated provider networks in order to drive down medical costs and improve quality; but they failed as consumer protests against restricted care sparked bipartisan legislation to enact a “patient bill of rights.” For its part, the ACA explicitly encouraged Accountable Care Organizations (ACOs), which are groups of providers that are rewarded for improving quality and cost control by coordinating care. ACOs have proliferated in number but doubts persist about its effectiveness—the CBO and independent studies project quite small reductions in annual national health spending, little sustained quality improvements, and new risks to vulnerable populations. ^{Footnote 42}

The ACA’s rejection of Medicare’s model of rate regulation is striking given its effectiveness. Independent research demonstrates that medical providers, especially hospital systems that dominate regions, are quite effective in extracting generous payments from insurers, who pass them along to those paying premiums. ^{Footnote 43} Deploying government authority to reduce the prices charged by hospitals, physicians, and other providers has effectively contained costs in Medicare and in Western Europe, Canada, and Japan. Joseph White argues that rate regulation that restrains provider prices “dramatically increases payer power [and] must substantially reduce billing expenses.” ^{Footnote 44}

In short, the ACA has brought into the arenas of public deliberation and collective choice much of what had been cloistered in privatized decision making among individuals, medical providers, and businesses. Even as public/private boundaries shifted, however, the disruptive impacts on the business of health care have, in the ACA’s early years, been tempered.

Socializing the Conflict

Research on “policy effects” suggests that the passage and implementation of the ACA can be expected, over time, to impact political identity and resources. ^{Footnote 45} Although seniors did not stand out as a coherent and potent political force before the enactment of Social Security, the program’s passage and development led its beneficiaries to consistently define themselves as having a political identity represented by a new political organization (American Association of Retired Persons [AARP]) and to turn out to vote at unusually high rates. ^{Footnote 46}

The implementation of certain aspects of the ACA may similarly impact new beneficiaries by changing perception of their stakes, increasing their motivation to participate in politics, and equipping them with the resources to mobilize. Although these changes are unlikely to occur quickly, early signs of politically consequential policy effects may be emerging.

The public’s interim general evaluations of the ACA seem contradictory, according to monthly surveys by the Kaiser Family Foundation. On the one hand, a majority or plurality consistently disapproves of the general idea of health reform. On the other hand, specific tangible benefits—such as the insurance exchanges and subsidies to purchase on them—are favored by over 70 percent of Americans, including majorities of Republicans.

Awareness and knowledge of the ACA’s benefits appears to be the key to unraveling the mystery of disapproval of health reform in the abstract and support for its specific provisions. Analysis of survey data collected in 2012 found strikingly strong connections between knowledge and support of the ACA: simulating the effects of full knowledge boosted support to 88 percent among Democrats, 74 percent among independents, and 40 percent among Republicans. ^{Footnote 47} This dynamic may help to explain initial findings from a panel study that I am conducting with Suzanne Mettler; the ACA’s implementation of new benefits between 2010 and 2012 reduced initial worries that reform would raise taxes and, in turn, contributed to support for health reform. Moreover, the advancing and increasingly salient implementation of the ACA’s tangible programs also appears to be sapping support for repeal, according to Kaiser surveys. In January 2011, 43 percent favored repealing the entire law (20 percent) or repealing it and replacing it with a Republican alternative (23 percent); by March 2014, the repeal support had declined to 29 percent—with only 11 percent backing full repeal and 18 percent a Republican alternative.

The ACA’s implementation varies across states, spotlighting quite distinct political dynamics. The rollout of health reform encouraged liberal states to move in progressive directions and, in a growing number of cases, confronted the conservatism of states (often in the south) that historically depressed program generosity in service of a low wage/low benefit economy. The ACA’s progressive federalism opened the door for some states to pursue more liberal health reform than national Democrats were able in 2010; Vermont is working with the Obama administration to receive a waiver to implement the single-payer plan it passed into law in 2011. As the ACA welcomed more liberal reform efforts, it also attempted to disrupt state conservatism and to invite new political forces; the federal government extended coverage to 5.5 million of Americans in states that refused to establish an exchange. The Supreme Court’s June 2012 ruling weakened the ACA’s stick to push states toward expanding Medicaid; but its carrots—along with pressure from hospitals, patients, and public interest groups—have convinced a growing number of states with Republican control to adopt it. ^{Footnote 48} Early research of state decisions on Medicaid suggests that public interest advocacy may be a significant influence (after controlling for political party and other potential factors). ^{Footnote 49}

The ACA may, over time, spur the formation of organized support for health reform from a broad coalition of Americans, challenging the one-sided advantages currently enjoyed by long-entrenched conservatives and narrow interest-groups representing insurers, physicians, hospitals, and pharmaceutical companies. Indeed, the widening acceptance of the ACA by stakeholders (including stalwart opponents such as private insurers in 2009 and 2010) reflects an acknowledgement of the changing balance of power. ^{Footnote 50}

The synergy of health reform, organizational formation, and political identity is showcased in California, which faced daunting challenges in enrolling people in the ACA—the ranks of its uninsured were one of the nation’s largest and were concentrated in diverse, hard-to-reach groups. But the organizational resources of California’s community and public-interest groups enabled the state to lead the country in enrollment; it accounted for about one-sixth of the entire country’s exchange coverage. ^{Footnote 51} In turn, the ACA’s resources and programs are supporting newer organizations and feeding back into the efforts of health reformers and other groups to encourage voter registration and broader political mobilization.

Of course, the ACA’s political effects remain uncertain and, in certain respects, may fall short of the mobilizing impacts documented by scholars of policy feedbacks. It is quite possible that the ACA’s “submerged” elements (such as insurance regulations) may fail to register with Americans as tangible benefits and may face a one-sided assault by the well-organized insurance industry. ^{Footnote 52} In addition, the continued poor administration of the ACA’s core components—exemplified by the failure of certain states to implement insurance exchanges or to administer them well—may put a drag on the public’s assessments. ^{Footnote 53}