Nearly four years after President Obama signed the Affordable Care Act, most of its major provisions are now in effect. And they appear to be as controversial as ever.
To help make sense of the partisan arguments, here are five things that are likely to be important measuring sticks of the law in 2014 and beyond.
1. How many people sign up for coverage in the insurance marketplaces and how many of them are in good health.
Asked to name the top three factors that will determine how the public judges the law’s success, University of North Carolina political scientist Jonathan Oberlander answers, “Enrollment, enrollment and enrollment.”
That issue draws outsize attention in part because it’s the easiest thing to gauge, says Oberlander.
The nonpartisan Congressional Budget Office estimated that 7 million people would sign up for private coverage in 2014, a projection that the White House endorsed. That would require an extraordinary surge between now and March 31, the end of open enrollment. As of Jan. 1, 2.1 million people had enrolled.
Perhaps even more important than the total is whether a significant percentage of healthy people sign up. The hope is that striking the right balance between sick and healthy will lead to attractive premiums for consumer while still leaving a profit for insurers.
Whether insurers increase 2015 premiums — either because they enrolled too few healthy people the first year or because mechanisms to protect them from losses failed to work – will be closely watched.
2. Will new enrollees be able to get medical care when they need it?
If new enrollees face a protracted period of appointment waits, difficulties finding specialists because of narrow insurance networks, or glitches in insurers getting their information, the national law could be seen as failing.
When Massachusetts implemented universal health coverage in 2006, many residents faced long waits for doctors’ appointments and crowded emergency rooms. Those waits have lessened, but haven’t disappeared. Nonetheless, polls show most people in Massachusetts now approve of the law.
3. What happens to the majority of Americans who get their insurance through their jobs?
While the administration delayed until 2015 the law’s requirement that employers with more than 50 workers provide coverage, Obamacare opponents say the law has already accelerated the trend of employers dropping coverage and steering workers to the exchanges.
While about 6 percent of large firms say they might drop coverage in the next five years (the vast majority keep it to stay competitive in hiring), the percentage of small employers who say they are likely to do so rose from 22 percent to 31 percent, according to a survey by consultant Mercer.
4. Will people find their insurance worthwhile?
How people evaluate coverage will depend on whether they get medical care when they need it — sort of like how people feel about property insurance after a big storm hits.
Because of the law, most people are receiving expanded benefits, including free preventive services such as cancer screenings, some vaccinations, contraception services and regular wellness exams.
Those who buy their own insurance will also get broader coverage, including mental health care, prescription drugs and can no longer be denied coverage because of pre-existing illnesses.
But that extra coverage means that some people are paying more than last year. But others will pay less, and some will get health coverage at virtually no cost to themselves through Medicaid or subsidies.
Watch for stories not just about people with chronic illnesses who finally are able to get insurance, but also about first-time buyers who are surprised to learn they have to pay deductibles before they can access coverage and may not always be able to see the doctors they want.
5. Will more states expand Medicaid eligibility?
Perhaps the single biggest factor in expanding coverage to those who are now uninsured will be if more states decide to expand Medicaid, as 25 states and the District of Columbia have already.
Politics, including pressure from hospitals, insurers and business groups, will likely determine whether more states opt in, allowing legal residents with incomes up to 138 percent of the federal poverty level to qualify for coverage.
It’s important to remember that states typically take their time responding to federal changes in health policy. Only 26 states adopted Medicaid when it began in 1966.