A Checkup for Obamacare

"In a few moments, when I sign this bill, all of the overheated rhetoric over reform will finally confront the reality of reform."

--President Obama, March 23, 2010

WASHINGTON -- Not exactly. Five years after the Affordable Care Act became law, the reality of reform remains hotly contested.

When it comes to the wisdom of the law, that's not surprising. After all, there is a legitimate ideological debate about whether it is a wise use of federal power to require individuals to obtain health insurance, or a wise use of federal resources to spend so much on subsidizing coverage.

What's more puzzling, and more disturbing, is the still-raging division over the real-world effect of the ACA. "It is important that everyone understand how absolutely fantastic it was for the people of this country," said Senate Minority Leader Harry Reid last week.

"It just isn't working," insisted Utah Republican Sen. Orrin Hatch. "In fact, it is, by most objective accounts, an unmitigated disaster."

Here's my take, after talking to numerous health care experts and examining the data: Notwithstanding its bumpy rollout, the law has accomplished its goal of expanding coverage -- at significantly lower cost than expected.

Certainly, the president overpromised when he told people that if they liked their health insurance they could keep it; by its own terms, the law set new standards for required coverage. Certainly, some individuals, particularly younger and healthier customers, find themselves paying more; again, such winners and losers were an inevitable consequence of the individual mandate and minimum coverage rules.

Meantime, the scariest warnings -- of employers rushing to drop coverage and insurance markets ensnared in death spirals of ever-rising premiums -- have not come to pass.

Where the law has yet to fully deliver on its promises -- and some wonder whether it will -- is in the area of cost containment and quality improvement. Health care cost growth has slowed dramatically, but there is a continuing debate about what role the ACA played. In any event, health care continues to consume an unacceptable 17 percent of GDP.

Some facts (space doesn't permit me to go into every detail) to back up these assessments:

Coverage. More than 16 million Americans have gained insurance, including through the state and federal exchanges, the expansion of the Medicaid and Children's Health Insurance Program, and the requirement that children be allowed to remain on parents' policies until age 26, according to the Department of Health and Human Services.

The increase would be even greater had the Supreme Court not made the Medicaid expansion optional for states, of which 27 have accepted generous federal funding to cover those earning up to 138 percent of the poverty level. Still, the share of uninsured among the nonelderly (those over 65 obtain health care through Medicare) is at its lowest level ever recorded.

As predicted, millions remain without coverage. According to a January analysis by the Congressional Budget Office, in 2015, 36 million nonelderly people will be uninsured. By 2025, that number will drop to 31 million, one in nine nonelderly residents.

Of those, about 30 percent are unauthorized immigrants ineligible for help; 10 percent are ineligible for Medicaid because their states chose not to expand coverage; 15 percent to 20 percent are people eligible for Medicaid but not enrolled; and the rest (40 percent to 45 percent) simply decided not to purchase insurance.

Costs. Health care costs and premiums for employer-sponsored insurance (the way most of us obtain coverage) have been rising at their lowest levels in years. On the exchanges, premium increases during the law's second year mirrored that modest growth -- averaging 2 percent on some midrange plans and 4 percent on the lowest-cost ones, according to the Kaiser Family Foundation.

Subsidies are available for those with incomes up to 400 percent of the poverty level; 85 percent of those purchasing insurance on exchanges obtained monthly subsidies, averaging $263 in the 37 states participating in the federal exchange, according to HHS. More than half selected plans with monthly premiums of $100 or less, after subsidies.

Still, some individuals encountered sticker shock. While average premiums fell in 14 states, 10 states saw double-digit increases, according to The Commonwealth Fund.

Relatedly, slower growth in health spending has saved the government money. According to the CBO, the net cost of coverage provisions for the five years ending in 2019 will be 20 percent ($139 billion) less than originally projected.

That's a snapshot of the reality of reform. Not that it's apt to make much of a dent in the overheated rhetoric.

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Ruth Marcus' email address is ruthmarcus@washpost.com.