The Affordable Care Act's success has been a mixed bag, admits Kathleen Sebelius, the Obama administration Health and Human Services secretary who was the first administrator responsible for its implementation. She gives the law and the marketplaces set up under it "maybe a 'B' or 'C-plus.'"
"It isn't that the marketplaces are failing in their own," Sebelius told the Washington Post's "Health 202" reporters. "The framework in which they operate is—I would say—more constrained than could be helpful." By "constrained," she means subject to politics, basically. After the initial implementation of the law, it was clear there were changes to the law that were necessary for its greater success, changes a Republican House staunchly refused to consider. A nihilistic and toxic White House bent on sabotaging the law has just compounded that.
But from the law’s very beginnings in early 2014, it was clear that states embracing it were seeing much more success in enrollments and expanding coverage. That has remained true since, especially for the states that not only expanded Medicaid but also set up their own insurance exchanges. Eleven states and the District of Columbia chose to run their own exchanges rather than operate through the Healthcare.gov portal. Those states have also been more active in working with insurers and also in promoting enrollments. Nine of the states have extended the enrollment period and have been proactive in working toward improvements allowed under state law. Two Democratic governors, California's Gavin Newsom and Minnesota's Tim Walz, are even exploring how to expand the subsidies to a larger population, making it more affordable for more people.
The results show in enrollment for the 2019 plan year. In the 11 states with their own marketplaces, enrollments have held steady at about 3 million people. In the states using the federal exchange, and with that exchange relying in large part on the Trump administration for enrollment help, numbers dropped. About 8.7 million enrolled in 2018, but 8.4 million signed up for this year. It shows just how vulnerable to political sabotage the law is, as Sebelius points out. "There has never been a piece of legislation that is as massive and complicated as the Affordable Care Act where there was an absolute refusal of the U.S. Congress to ever try and make it work—to even provide technical assistance to clarify issues that might not be clear," Sebelius said.
Part of the problem was the complexity President Obama and congressional Democrats built into the law in an effort to keep as many industry stakeholders as happy as possible. It's a total Rube Goldberg device, with an insane number of moving parts. But industry did eventually buy in and has worked to make it as successful as possible, given the headwinds of Republican resistance. That's a consideration for all Democrats working on the next iteration of healthcare reform. It's going to be hard to bulletproof any law from federal courts that are increasingly under Trump’s sway, but it has to be part of any calculation.
Because Republicans, and the federal judiciary they're building, will always put corporate profit ahead of saving actual people's lives.