Intended for healthcare professionals

Observations Yankee Doodling

How will we know if Obamacare has “worked”?

BMJ 2014; 349 doi: (Published 10 November 2014) Cite this as: BMJ 2014;349:g6725
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, and associate editor, The BMJ
  1. dkamerow{at}

It depends on what you think it was intended to do

As the beginning of the second annual sign-up period for the US Affordable Care Act approaches, it is reasonable to ask whether or not the act, “Obamacare,” has been a success. As with most things, where you stand depends a lot on where you sit. Republicans commonly call Obamacare an utter failure, and Democrats defend it as increasingly successful. In reality, of course, it is way more complicated than that.

Take, for example, the experience of two family friends, both rather liberal Democrats. The first is in a family with a chronically ill adult. As a result, they had been paying huge monthly premiums for adequate coverage and found, to their delight, that they could dramatically reduce their monthly premiums under the Affordable Care Act. The second friend discovered that, contrary to promises that he could keep his insurance, his health plan was cancelled. His income level precluded subsidies, and the premiums for his new plan doubled. In both cases, the difference was thousands of dollars a year, but in opposite directions. Needless to say, the first family is a big fan of Obamacare, the second an instant (and eternal) enemy.

Individual anecdotes are telling and often heart rending—the woman who now gets her cancer treated, or the man who can no longer afford his crucial drugs—but in the end they don’t really help decide anything. We need to look at the national picture to try to get an overall assessment of the success or failure of the law. To do that, you have to decide what success looks like. Is it simply not failing, contrary to conservatives’ dire predictions? Is it political popularity? Is it a thriving healthcare industry? Is it enrolling more people for health insurance? Or is it something more systemic and overarching?

Obamacare, despite its vigorous opponents, has decidedly not failed. It has survived many repeal attempts, court challenges, defunding threats, and more. Although Republicans still say they want it abolished, few think that this is even remotely likely, especially now that millions more people actually have health insurance. The widely predicted “death spiral” of increasing rates and decreasing participation has simply not happened.

Politically, however, the law is a failure. It has been a disaster for the president, lowering his popularity, fueling the “Tea Party” and its candidates, and contributing to the gridlock in Congress. Poll after poll reports that a majority of the US population are unhappy with the law.

Despite predictions of its immediate demise, the US healthcare industry is doing well under Obamacare. The insurance companies have figured out how to adapt and remain very profitable. Hospitals have taken some losses, with cuts in Medicare payments and penalties for readmissions, but an increase in coverage levels means more paying patients.1

If the metric for success is simply more people with health insurance, then Obamacare has worked. Everyone agrees that somewhere between eight and 11 million fewer people were uninsured in the past year, an overall decrease of about 25%.2 These new enrollees are in both the government Medicaid program (in half the states) and private plans.

But more coverage does not necessarily mean better (or even more) care. The so called “triple aim” has become the holy grail for healthcare improvement: better health, better healthcare, and lower costs. Achieving the triple aim would unquestionably make Obamacare a success. The act had provisions targeted at each of these goals, but in many cases it is hard to document changes after just one year. One often has to be content with fragmentary evidence about precursors to the big goals.

Costs are probably the easiest to document. No one denies that the annual increases in US spending on healthcare have moderated since the law passed in 2010, but there is no consensus on whether it was Obamacare or the recession that slowed the spending increases. Similarly, the dramatic increases in insurance premiums predicted by some for the second year of the program have largely not materialized, though some policies in some states have substantially increased their charges.

It is probably too soon to tell whether healthcare and health outcomes have improved because of the act. More doctors use electronic medical records, which should improve the quality and coordination of care. More people are getting preventive care, which should lower the prevalence of some chronic diseases—eventually. And younger adults, some of whom got access to affordable insurance four years ago, have shown some positive trends along with increased insurance coverage, including increased mental health treatment, increased healthcare spending, and more people reporting having a primary care doctor.3 These are all good signs but hardly compelling proof.

So we will probably have to wait a few years to see what the real outcomes of Obamacare are, but a new analysis makes it clear what is really going on.4 It points out that what we are seeing is nothing less than the beginning of a revolutionary change in the fiscal inequality of Americans, through distribution of health insurance and insurance subsidies to the very groups who have historically had the lowest rates of income and coverage: the young, black people, Hispanic people, and those who live in rural areas. It is not universal coverage, but it is a big start.


Cite this as: BMJ 2014;349:g6725



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