Intended for healthcare professionals

Observations Yankee Doodling

Obamacare’s rocky road

BMJ 2013; 347 doi: (Published 12 November 2013) Cite this as: BMJ 2013;347:f6805
  1. Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
  1. dkamerow{at}

Is there more good than bad here? Who benefits and who suffers?

Health reform has been in US headlines almost every day for months. In September and October the scuttling of “Obamacare” was the major bargaining chip the Republicans tried to use in their battle with the Democrats over shutting down the federal government and raising the debt ceiling. When that failed and they had to relent and reopen the government, the Republicans changed their focus from killing Obamacare to spotlighting the problems people have had trying to sign up for it through the website.

Given all that has happened, can the Patient Protection and Affordable Care Act (Obamacare) actually protect patients and make care more affordable?

To answer that question a bit of background is in order. Obamacare was enacted in 2010, with no Republican support and no fine tuning of the law between the two houses of Congress.1 As a result, the mammoth law, which was enormously complex and comprehensive at best, is full of minor (and some major) problems and inconsistencies.

Then the Supreme Court was asked to rule on the constitutionality of the law and did so in 2012. While the court generally approved the law, it negated a crucial section that required all 50 states, using funds from the federal government, to broaden their Medicaid programs. Since then, half of the states have opted out of expanding their Medicaid programs, and as a result many fewer poor people will get coverage than was originally envisioned.2

Meanwhile, in the three and a half years since the Affordable Care Act was passed, many of its positive provisions have been implemented. Children can now stay on their parents’ policies up to age 26, providing coverage for many previously uninsured young people. Evidence based preventive services are now covered in all policies without deductibles or copayments. Pre-existing medical conditions, previously a huge barrier to individual health insurance, now cannot be used by insurance companies to exclude coverage.

But these were mere preliminaries to the central provision of the law, scheduled to begin in 2014: the requirement that all Americans obtain healthcare coverage. Several mechanisms were created to make that possible: state based insurance exchanges, to give people a choice of policies; subsidies to help those who could not afford coverage; and extended Medicaid coverage to help the poorest people. All of this was to be accomplished through the massively complex website, which was to inform, register, advise, and enroll millions of people from 1 October.

As everyone knows, it didn’t happen.

The website was a bust. It collapsed under the crush of traffic, and an embarrassed administration said that it would take weeks or longer to fix it.3 Newspapers detailed the numerous glitches and warnings about the website that were ignored, and Obamacare’s opponents gleefully demanded the head of the health and human services secretary, Kathleen Sebelius. Frustration mounted as only a tiny number of Americans were able to enroll in the first month of the program.

At the same time, it became clear that one of the president’s most visible and consistent promises about Obamacare from the very beginning was not true. He had repeated over and over that people who had healthcare insurance and liked it could keep their policies in the new system. It turned out that for a small but visible group of people this was not true, and they are now getting cancellation notices: no insurance for them after 31 December.4

Cue the sob stories from affected people, usually with cancer, who immediately do what anyone who desperately needs insurance and loses it does: get their story published as an op-ed by the Wall Street Journal,5 which accompanies it with an editorial.6 To be fair, supporters of the law immediately chimed in with sob stories of their own. A New York Times columnist wrote about two men who were likely to die for their lack of health insurance before Obamacare could kick in, one of whom was the columnist’s college roommate.7

What is needed here is not another anecdote about someone who couldn’t sign up for Obamacare or another who is suffering because of a lack of coverage but a clear, somewhat rational view of how things are going on a population basis. Here goes.

Sign-up for 2014 coverage has been an unmitigated disaster. It needs to get fixed, and deadlines should be extended so that everyone has time to enroll. Obama misled a small proportion of people with individual coverage who have lost their insurance, though many of them will be able to sign up for replacement coverage that is as good or better. That said, Congress and the administration need to figure out a way to restore coverage to those who were deceived by Obama and lost their insurance.

Don’t confuse all these alarmist concerns with the main issue here, though. The core of need is health insurance coverage; one American dies prematurely every 20 minutes because of inadequate coverage and access to care.8 The troubles and travails of the few pale in comparison with this fact, which is what Obamacare—if implemented correctly—was designed to fix. The rest, though it sounds heartless to say it, is noise.


Cite this as: BMJ 2013;347:f6805



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