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The health exchange reckoning

BMJ 2014; 348 doi: (Published 21 March 2014) Cite this as: BMJ 2014;348:g2300
  1. Edward Davies, US news and features editor
  1. edavies{at}

At the end of next week, the state insurance exchanges will close and any eligible citizen who has not signed up will face a tax penalty of $95 (£58; €69) or 1% of their income. You can also be certain there will be a postmortem examination of the success of the past six months’ recruitment campaign.

Figures for the month indicate that 4.2 million people have signed up to the exchanges so far (doi:10.1136/bmj.g2140) and these figures are important because much of the success or failure of the Affordable Care Act will be judged on how many more people are insured.

But these numbers are complicated. For a start, although 4.2 million have selected a health plan we do not know how many have paid their first premium. It is also true to say that far more than this number will have become insured through other aspects of the law such as the expansion of Medicaid and provision to insure children under the age of 26. Estimates of the real number of newly insured range from 4 million to 14 million at the time of writing.

Indeed John Boehner, the most senior Republican in the House, declared last week that Obamacare was causing a net loss of insurance as millions of people’s plans became ineligible under the new rules. His simplistic math has been widely and soundly lambasted in the media (, but his assertion shows there are many ways to view the data and the situation is far from simplistic.

There was, however, one particularly sobering bit of data that emerged from pollsters Gallup this month. Although they are recording a continual fall in the number of uninsured since the opening of the insurance exchanges in October (down 2%), the percentage of uninsured in the first quarter of this year was still at 15.9% (

Not only is that figure a considerable proportion of uninsured people, but a notably larger proportion of the country than were uninsured when Obama took office in 2008 (14.4%).

That people are getting insured who would not otherwise be is undeniable, whether this law is the success that its advocates crave is going to be tough to judge.


Cite this as: BMJ 2014;348:g2300