The ACA was passed to expand insurance to the more than 45 million Americans who lacked it. It was also sold as a way to reduce national health care costs and bring down premiums, but those were secondary objectives.So far, Obamacare is failing not only at those secondary goals but at its primary one as well. WaPo reports on two new surveys that found that overall enrollment by the previously uninsured remains very low:
One of the surveys, by the consulting firm McKinsey & Co., shows that, of people who had signed up for coverage through the marketplaces by last month, just one-fourth described themselves as having been without insurance for most of the past year […]The second survey, by researchers at the Urban Institute and based on slightly older data from December, shows that awareness of the new marketplaces is fairly widespread but that lower-income Americans and those who are uninsured are less likely to know about this new avenue to health coverage than other people.
Furthermore, 47 percent of the uninsured who did enroll haven’t paid any premiums. This is already being picked up as a major blow for Obamacare. And it is. But the more interesting question is why the uninsured are so resistant to getting insurance. After all, insurance is supposed to be a product we all want. It provides financial security and peace of mind and effectively increases incomes. And yet, after passing a law that penalizes the uninsured, subsidizes premium costs for poor Americans, and pours millions of dollars into outreach to that population, the Obama Administration has made little headway in convincing them to sign-up.This is a puzzle at the very heart of our health care system. Opponents of the law want to pin it on the details of the ACA. The uninsured are passing because the ACA raises premiums or requires more comprehensive rather than catastrophic insurance. A different law would be more effective in pushing universal coverage. There’s some truth to this, and claims by the Obama Administration that they aren’t even tracking how many uninsured sign up aren’t helping its case. On the other side, supporters of the law want to blame it on poor outreach or Republican fear-mongering, causes that don’t reflect failures of the law itself.But perhaps the source of these low sign-up numbers goes much deeper. Consider this post by Megan McArdle from January:
U.S. Census figures say that 45 million people go without insurance every year in this country. To be sure, some of those are undocumented immigrants, who are unlikely to show up at a government-run exchange; others are legal residents who may not be eligible for subsidies. But where are the rest? We just created a giant new entitlement to take care of these people. Why aren’t they showing up to take advantage of it? […]There may be something seriously wrong with our understanding of who the uninsured are, and what they are willing and able to buy in the way of insurance. I don’t know exactly what the fault may be in our understanding. But if the numbers stay this low, I’d say we need to reassess the state of our knowledge about the uninsured—and the vast program we created to cover them.
This is a sobering possibility, but one that grows more likely with every study about low enrollment numbers. Properly functioning national markets are hard enough to understand and influence, but U.S. health care is nowhere near a functioning market. The truth is that we might not not understand health care well enough to make effective national policy about it. If that is so, much of the debate has been on the wrong track for a long time now.