ObamaCare left 2015 in a stronger position than it began, though the threats of rising premiums, skittish insurers and challenges from Washington loom for the president’s signature health law during his final year in office.
The law, formally known as the Affordable Care Act, emerged largely unscathed from a government funding debate last month, a far cry from a 2013 shutdown fight in which opponents delivered fiery floor speeches against it and plotted its demise during infamous meetings at Capitol Hill’s Tortilla Coast restaurant.
HeathCare.gov, the federal insurance exchange, seems to be functioning now and even handled record traffic ahead of a Dec. 15 enrollment deadline.
The storm has calmed slightly, at least until a new president arrives, and — depending on his or her party — sets to work trying to dismantle or strengthen the law.
So how well is ObamaCare actually working?
There has been a historic increase in the number of people with health insurance, and the law appears at little risk of fully collapsing. But with 29 million people still uninsured, can ObamaCare go further? And how much will it all cost, both to the individual and the system as a whole?
“We're through the risk of ‘Oh my goodness, it might not work,’” said Bob Kocher, a former Obama White House adviser on health reform. “I think we're now in the figuring out how to make it work well mode.”
There have always been some fears that not enough healthy people would sign up to balance out the sick, in what is known as the risk pool. But Larry Levitt, an expert on the law at the Kaiser Family Foundation, pointed to signs the enrollment mix is growing and improving.
“The risk of the law collapsing is very slim if not non-existent,” Levitt said. “Enrollment is still growing, the risk pool is likely improving. At this point, the law seems perfectly sustainable.”
“ObamaCare is alive and working, if not perfectly,” he added. “The biggest concerns are around affordability and whether more people will enroll.”
The law’s main goal was straightforward. After decades of failed attempts by presidents since Harry Truman, Democrats pushed to give the United States something close to universal healthcare and drive down the ranks of the uninsured.
And so far, about 16 million people have gained health coverage, according to the Centers for Disease Control and Prevention. In 2013, before the coverage expansion kicked in, there were 45 million uninsured people. In 2015, there were 29 million.
The uninsured rate is down to a record low: 9 percent.
But the law has a long way to go if it is to achieve anything like universal coverage. The prospects for quick growth grew dimmer in October, when the Department of Health and Human Services (HHS) released its projection for 2016 signups. Ten million people would be enrolled by the end of 2016, it estimated, just 900,000 more people than at the end of 2015.
That left the administration fending off the idea that ObamaCare has reached a “plateau.”
HHS Assistant Secretary Richard Frank said there was no plateau, but “we are seeing a much longer path” to signing up the rest of the uninsured.
Since then, though, the numbers have been more encouraging for the law. By the preliminary deadline of Dec. 15, about 6 million people had signed up, compared to 3.4 million at the same point in 2014. The percentage of enrollees under age 35 has also ticked up, a positive sign for bringing in enough healthy people.
“Based on the latest numbers they should comfortably beat their enrollment target,” Levitt said.
Still, it appears unlikely that the sign-up numbers will approach what the Congressional Budget Office projected they would be: as many as 20 million enrollees in 2016. Defenders say that’s partly because fewer employers are dropping coverage and pushing people into ObamaCare.
“At best, we're poised for modest enrollment growth for the next few years,” Levitt said.
Still, having insurance is not the end of all health worries, as Republicans are quick to point out. “People have Washington-mandated coverage, but they still can’t afford to get care,” said Sen. John BarrassoJohn BarrassoGOP eyes big gamble on ObamaCare Reid defends relationship with McConnell in farewell speech Overnight Energy: Trump taps EPA foe to head agency | Energy reform bill officially dead MORE (R-Wyo.), a leading ObamaCare antagonist.
High deductibles — the amount one has to pay before insurance kicks in — in ObamaCare plans have been at the center of the debate.
A Commonwealth Fund study called the deductibles and out-of-pocket spending limits under the most popular ObamaCare plans “daunting.”
The deductible for a silver-level ObamaCare plan, the most popular, is $2,951, according to the study, compared to $1,217 for the average employer-sponsored plan.
Still, ObamaCare enrollees with lower incomes are eligible for extra financial help that dramatically lowers these out of pocket costs.
One of the main worries, though, is that while there are heavy subsidies to encourage low-income people to sign up, there is less financial help to entice middle-class people.
The courts and Congress loom as well. While major changes appear unlikely before a new president takes over, lawmakers could keep chipping away at a range of unpopular ObamaCare taxes.
The lawsuits are not over either. A case brought by House Republicans arguing President Obama overstepped his authority in making certain payments under the health law is working its way through the lower courts.
Premiums also climbed faster this year as insurers adjusted to a mix of ObamaCare enrollees that was sicker and more costly than they expected. Still, premiums were about 15 percent lower than expected in the first year of the law, meaning that much of the growth is just catching back up to the initial projections.
“Plans are still covering individuals that have very serious and chronic conditions that come at a very high cost,” said Clare Krusing, spokeswoman for America’s Health Insurance Plans, the insurer trade group.
United Healthcare sent out shockwaves in November when it announced that it might pull out of the ObamaCare marketplaces in 2017 because it was losing money.
But several other insurers pledged their commitments to the marketplaces in the wake of that announcement, and the latest numbers from the administration show enrollees appearing to get younger and healthier, partly because the penalty for lacking insurance is growing.
“If enrollment continues on the path it is now, I'd be very surprised if any major insurers dropped out in 2017,” Levitt said.
Insurers and health experts alike say that the long-term answer is to contain rising healthcare costs, the proverbial bending of the cost curve.
It is still an open question how far ObamaCare can go in that regard to cut down on the roughly 30 percent of healthcare spending that is considered just to be waste.
But ObamaCare has at least made a start by setting in motion a range of projects that seek to transform healthcare payments from rewarding quantity to rewarding quality.
Those programs are continuing despite lawmakers last month successfully delaying another of the law's cost-control measures, the "Cadillac tax" on high-cost insurance plans.
Kocher, the former White House adviser, said he has seen a “tsunami of interest” from doctors in setting up Accountable Care Organizations spurred by the law, which are groups of doctors that coordinate care and are paid based on the quality of outcomes for patients.
He argued the new incentives are making a lasting change in the way the healthcare system will work.
“I think that’s unstoppable,” he said.