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Reflecting on Health Reform: Two Weeks in October


This was a tumultuous two weeks in the short life of the coverage expansion provisions of the Affordable Care Act (ACA). Technical flaws affecting the federal insurance marketplace have largely obscured the successful rollout of many other parts of the law over the past three years: the coverage of millions of young Americans under their parents’ insurance policies; premium refunds to still more millions as a result of limits on administrative costs of private insurance; cost-free access to a range of preventive services; and more.

There is no denying the seriousness of problems with marketplace websites, though their full extent and consequences are difficult to assess. At this point, only the IT experts in the belly of the beast—in the Centers for Medicare and Medicaid Services and the IRS, the federal contractors, and participating state governments and insurance companies—have any real understanding of what’s going on and what to do next. And even they may not yet have fully diagnosed where the code is breaking down.

From another viewpoint, however, this hasn’t been such a bad two weeks for the law. A major effort to kill it failed decisively, and the consensus among Republican leadership seems to be that it will be impossible to defund or repeal the ACA as long as President Obama remains in the White House. A Wall Street Journal columnist went so far as to liken the defunding crusade to the heroic but utterly disastrous charge of the British Light Brigade during the Crimean War. This means that the law’s implementation will likely continue at least until the next president takes the oath of office on the Capitol steps in January 2017.

In the long term, these political developments are far more important than any technical failures, and that is precisely the reason that opponents were so desperate to stop the ACA during the first weeks of October. They correctly perceive that by the time a new president takes office—whether that person is a Republican or Democrat—the law will be a fait accompli. At a minimum, the 15 states that are running their own marketplaces, some with considerable success, will probably have enrolled millions of previously uninsured Americans in Medicaid or private health insurance plans. State-run marketplaces account for half of the nearly 500,000 individuals who have already completed applications. We learned last week that Oregon has already cut the number of its uninsured by 10 percent. In the first five days, California created over 43,000 accounts and recorded nearly 1 million website visits. New York had received 80,000 applications by October 11. Kentucky had created 29,350 accounts by October 10.

Beyond that, even if it takes months, the federal government will find a way to make its online marketplaces work. The avalanche of interest in the exchanges (14.6 million visits to by October 11) that helped take the federal system down in its first week suggests that currently discouraged consumers will migrate back to the federal website once it is up and running. The insurance available in the exchanges will not be perfect for everyone. But there will be opportunities to improve all levels of coverage.

Three years is plenty of time for the ACA to become a fact of American life, like Medicare, Medicaid, and Social Security before it. If Republicans regain the White House in 2017, they may then face the same difficult choice that President Richard M. Nixon did in 1968 when he became the first Republican president after the enactment of Medicare and Medicaid in 1965. Republicans had strongly opposed these programs. No one knew whether Nixon would try to dismantle them or make them work. He did the latter. In three short years, the elderly had come to love Medicare, and no national party could survive their alienation.

By 2016, Hispanic voters may have come to rival the elderly in the national political firmament, and with their large rates of uninsurance—30 percent—they will be major beneficiaries of the law. Despite the ferocity of Republicans’ current opposition to the ACA, cooler heads may prevail when faced with the choice of ripping coverage from the most rapidly growing voting bloc in the United States, or trying to patch the law's flaws and make it work better for potential voters, and the American people generally.

Technologically, getting the exchanges to function is ultimately doable. It’s just a matter of time and effort, trial and error. Politically, taking health insurance away from millions of Americans is akin to defying the laws of gravity. Despite the fireworks, this wasn’t a bad two weeks, on balance, for supporters of the ACA.

Read other posts in David Blumenthal's "Reflecting on Health Reform" series:

The Presidential Health Care Curse: Why Do They Bother?

A Tale of Two IT Procurements

The Marketplace Experience: Month One

Buckeye Bellwether?

Publication Details



D. Blumenthal, Reflecting on Health Reform: Two Weeks in October, The Commonwealth Fund, October 2013.