Whenever somebody says that an argument is settled, you can be sure that it is not. If it were settled, there would be no need to say so. No president will hold a press conference to announce that the argument over the prohibition of alcohol is settled, precisely because it truly is settled. So when President Obama declared the debate over his health-care law “settled” and “over,” as he did at an April 17 press conference, his performance was self-refuting.
The president was declaring victory in the Obamacare wars because more than 8 million people have enrolled in an insurance plan through the law’s exchanges — at least if we use the administration’s loose standard for enrollment. (How many of those enrollees will ever pay their premiums is unknowable.)
Compared with the broken-website days of October and November 2013, that enrollment figure is a magnificent achievement. In any other context it is less impressive. To see why, let’s review the arguments that each side of the Obamacare debate has been making during the debate, which has been running since the spring of 2009.
Supporters of the law, very much including the president himself, made three principal claims on its behalf while getting it through Congress and defending it afterward. First, it would dramatically expand coverage. In February 2013, the Congressional Budget Office projected that in 2014 the law would provide coverage to 14 million people who would otherwise have lacked it. That estimate, note, was made even after the Supreme Court, on a 7–2 vote, ruled that states had to be given more leeway to refuse to participate in the Medicaid expansion that is one of the law’s main tools for expanding coverage.
Second, the law would control costs, reducing both premiums and deficits. President Obama said that premiums for the average family would drop by $2,500. And third, the plan would leave existing insurance policies alone. You’d be able to keep your plan, and your doctor, if you wanted.
The critics argued that the law would instead increase costs, retard innovation, and lower the quality of care. Premiums would increase for many people. The law would prove more disruptive to existing insurance arrangements than the president and his allies were saying. Jobs would be lost. And the critics made additional claims — that the law would unconstitutionally expand governmental power and violate conscience rights — where the dispute didn’t so much concern the effects of the law as how to characterize those effects.
What the critics rarely said in 2009, 2010, 2011, 2012, or most of 2013 was that nobody would sign up for coverage on the exchanges, or that the law would fail to increase the percentage of Americans with coverage. They said that much of the increased coverage would be of low quality, and that the coverage expansion could be accomplished at a lower cost. Some of them talked about the possibility of a “death spiral” in which Obamacare’s regulations reduced the incentive to buy insurance so much that the market collapsed — but for the most part they thought of this as something that would take a long time to happen if it happened at all. The argument over Obamacare, that is, has mostly taken for granted that more subsidies for health insurance could lead to more people having it.
Our experience of the law has not been quite what either side predicted. In part that’s because the law has not been implemented as written. The employer mandate, which critics put at the center of their case that the law would kill jobs, has not been put into effect. (The Congressional Budget Office has, however, found that other features of the law, such as its reduced subsidies as people move up the income scale, will discourage work by the equivalent of 2.5 million jobs a year.) The administration has put regulations that threatened to cancel many existing plans into a kind of legal limbo.
By the standards President Obama set, however, the law is closer to a failure than a success. Its biggest achievement is a modest decline in the percentage of Americans without insurance. And it is modest: Even the highest estimate of the increase in coverage (the one derived from Gallup polling) suggests that the percentage of Americans uninsured has dropped merely to around the level of 2008. At this point at least, even the projection the CBO made just a year ago (of 14 million fewer uninsured) seems implausibly optimistic.
Obama’s other promises — which were stated in strong terms — have largely failed to come about. Premiums have not dropped by $2,500 per family; it is not clear that the law has brought them down, on average, at all. For millions of people they have gone up, thanks to the plan’s regulations. Supporters say that in return for these higher premiums people are getting better coverage (and social justice). It’s a debatable point, but it’s not the way the law was sold.
Supporters of the law took credit when medical inflation came in low in the first years after the law’s passage, but it had been on a declining trend for a decade; and the most recent estimates suggest that the trend may have just ended.