It’s a very big day for American health care: Today, the health insurance exchanges called for by the Patient Protection and Affordable Care Act—a.k.a. Obamacare—open for enrollment, offering coverage that kicks in at the beginning of next year.
The exchanges are the core component of the largest and most transformative overhaul of the U.S. health system in decades, and the vehicle for the law's massive expansion of health coverage. And yet, despite the fact that Obamacare has been law since 2010, no one knows quite what to expect as these government-run insurance marketplaces open for business.
Critics have warned of disaster, pointing to a slew of delays and technical troubles with the exchanges, and Congress has allowed the federal government to enter a partial shutdown as a result of conflict over the health law. Supporters of the law have promised that Obamacare will usher in a new age of widespread affordable coverage. But even President Obama has admitted that the rollout won’t be without its “glitches and bumps.”
Over the last week, I asked a half dozen conservative and libertarian health policy experts what to expect from Obamacare in the coming days and months, and in the years beyond. Here’s what they told me. (Quotes have been condensed and edited for clarity.)
On Opening Day
James Capretta, Ethics and Public Policy Center Senior Fellow and Former Bush Administration Health Official: “On October 1, you're going to see a very uneven beginning to the program. Some states are going to be largely ready to go and have a big presence on the ground to get people signed up. And then in some states, literally nothing's going to happen for a while. There may be a start up process on Oct 1, but there aren't enough people on the ground to know to actually do anything about it. So, I don't think there will be much enrollment in the early days or weeks. You're going to have a very uneven regional aspect to this, where some places it's up and going and some places it's literally it's a dead stop still.”
Michael Cannon, Cato Institute Director of Health Policy: “When it takes full effect in January and all 50 states start to receive those subsidies, you're going to have millions and millions more people dependent on government health insurance. And you're going to have an industry receiving an even larger chunk of its already bigger revenue stream from the government, either directly or indirectly through implicit taxes. So if Obamacare takes full effect, it will vastly expand the constituency for higher taxes and greater government spending on healthcare.”
Devon Herrick, National Center for Policy Analysis Senior Fellow: “I'm not sure if anyone really knows what to expect. But what we wonder about is that the administration—and the insurance companies as well—is very concerned that when the exchange is opened the only people who will be lining up for coverage will be the early retirees, those who have preexisting conditions. And of course to keep the Affordable Care Act premiums affordable the administration and architects, their goal was to get those healthy young invincibles—people who have few health needs that are willing to spend more than their expected cost—so the older, less healthy people could get coverage at a price they can afford and would like to pay. That's going to be a reach. A lot people are afraid the healthy folks may not want to enroll and pay more than their costs should be or would be otherwise so that someone else gets a better deal.”
On Health Insurance and Premiums
Avik Roy, Manhattan Institute Senior Fellow and Romney Campaign Health Adviser: “Although there will be rate increases across the board under Obamacare, the biggest rate increases, and the rate increases that we're focused on here, are rates for people who shop for coverage on their own… Obamacare supporters excuse the rate increases, saying, well there's going to be subsidies and everyone will get subsidies so it doesn't matter that Obamacare drives up the underlying cost of healthcare. That's just not true on multiple levels. Subsidies aren't free. Taxpayers pay for them. They don't just magically fall from the sky. The subsidies really only benefit really poor people. Yes, there are a lot of middle class people who are eligible for subsidies, but the scale of subsidies that are available for people in the middle class and lower middle class as opposed to truly poor are relatively low and won't compensate for the dramatic increase in health expenditure and health insurance premiums people will see.”
Devon Herrick: The Department of Health and Human Services released a report saying average premiums would be around a hundred bucks for the cheapest bronze plan for 27 year olds who make about $25,000 per year. What I noticed about that was that young people who are making about $25,000 a year—even after the subsidy, that's an iPhone data plan payment. And some of those may think the iPhone data plan is more important than the coverage for a bronze plan that wouldn't really help them necessarily with what they need, which is an occasional doctor's visit.
Tom Miller, American Enterprise Institute Resident Fellow, Former Senior Health Economist with the Joint Economic Committee: “We have all kinds of projections about what the enrollment mix will be. People are just guessing on that front. There's no airtight result on that. And that'll make a big difference in terms of what will end up being the premium results.”
Michael Cannon: “The safe money is that it's going to increase the number of people with healthy insurance. But it could also decrease the number of people with health insurance as more people figure out, hey I can game the system, I can wait until I'm sick to buy insurance.”
On Implementation Challenges
James Capretta “Comparisons [between Obamacare’s rollout and Medicare Part D] are not very useful in the sense that the Medicare program already had an ongoing, direct relationship with its beneficiaries because of the rest of Medicare. They already knew who these people were. They had a communication structure already built to communicate with the Medicare beneficiary population through various means. They were able to build this infrastructure on the foundation of an ongoing communication relationship. There is no such foundation for the implementation of this law. Most of the people they're trying to reach are not connected to any kind of government benefit or system. They're trying to bring them into a system with which they'd have no existing relationship with. That's an entirely different proposition. It’s much, much, much harder.”