Ezra Klein, in his new capacity as one of the impresarios behind Vox, has written a pair of attention-grabbing posts — here, and then here — defending the proposition that Obamacare has, in some sense, “won,” and that conservatives who can’t come to terms with that victory can’t come to terms with reality itself. Reading them, it struck me that this argument would benefit from laying down some specific markers for the near future, because Klein seems to move back and forth between two definitions of success. At times, as when he writes that Obamacare “has won its survival” and allows that that “there are still many good critiques to make” of the law, he seems to be using a narrow definition, with which I mostly agree — the law won’t collapse under its own weight, the enrollment levels are high enough to make a return to the coverage status quo ante unlikely, etc. But when he uses language like “the individual mandate … is working” and “the law is back on its expected track,” and concludes that ”[Kathleen Sebelius] can leave with the law she helped build looking, shockingly, like a success,” it implies a stronger definition of victory, in which Obamacare isn’t just continuing, isn’t just unlikely to be swiftly repealed, but is clearly succeeding as a policy in basically the way its advocates predicted that it would.
So I think it would be useful for the law’s supporters to specify the metrics/numbers/outcomes that would vindicate the latter claim. Here are three fronts where specificity would be helpful:
Enrollment. In the summer of 2012, after the Supreme Court decision freeing up states to reject the Medicaid expansion, the C.B.O. projected that 14 million Americans would get coverage under Obamacare in the first year, and 33 million by 2022. This February, after the botched rollout, the projections were 13 million in 2014, 27 million in the long run. The latest estimate, out this month, drops the 2014 projection down to 12 million, and the long-term number to 26 million. Meanwhile, the question of how many previously-uninsured people have gained insurance as of right now is, as this Vox explainer suggests, quite difficult to answer (and sadly, it may be about to become even more difficult), but a guesstimate of 9-10 million seems pretty plausible — and short, N.B., of even the C.B.O.’s more modest projection for this year.
So … how low can the numbers go before they start to make the law look like something less than a success? I assume that liberals will declare victory, with some reason, if Obamacare meets the C.B.O.’s current (reduced) expectations, this year and beyond. But what if it doesn’t? Suppose that by the end of 2016, when the C.B.O. expects the total number of uninsured to have fallen by 25 million, it’s only fallen by, say, 15 million instead — and most of the previously uninsured are getting coverage through Medicare, while the exchanges are mostly populated by people whose prior individual-market coverage was cancelled, either in 2014 or once grandfathering runs out. Will that be a success story? Presumably there’s some kind of shortfall that the law’s supporters would consider, if not a sign of outright failure, than at least a reason to be fairly disappointed with how Obamacare has worked. It would be helpful to know what they think that long-run number lies.
The cost curve. Before we entered into the agony of the botched roll-out, the law’s supporters were eagerly citing the persistently low rate of health care inflation as a sign that Obamacare was already working as designed, already having a beneficial effect. But as Vox’s Sarah Kliff reported yesterday, the latest inflation numbers cast some doubt on that hopeful hypothesis, with federal data indicating “that health care spending is now growing just as quickly as it was prior to the recession.”
Now this may be temporary: Some kind of cost inflation was always likely to be associated with this year’s roll-out of subsidies and Medicaid spending, and the law’s supporters can reasonably argue that we should wait a few years, until the coverage expansion (however large) has become a normal feature of the system, to judge Obamacare’s impact on inflation overall.
But at a certain point that judgment will need to be made. So, again, what should be the standard? What should be the baseline? Does Obamacare need to hold inflation to the low 2011-2012 pace (a pace, again, that many liberals wanted to credit to its early impact) in order to be counted as a cost-containing success? Does it just need to hold inflation below, say, a 10 or 20-year average? (Note that both on its own terms and relative to overall inflation, health cost inflation had been declining for seven years before Obamacare was passed — so just holding either rate below the average of 2000-2010 would not actually be that impressive.) In other words — what does the Affordable Care Act have to achieve in order to live up to its name?
Health outcomes. It’s been crowded out by the website drama like everything else, but one of the major divides between Obamacare supporters and skeptics was over whether, and to what extent, the law would literally be a lifesaver — with writers like Klein famously invoking “lives saved” figures in the hundreds of thousands during the run-up to the law’s passage, while doubters cited the surprisingly-weak link between insurance status and health outcomes, and raised the potential public-health downsides, in terms of innovations lost or never sought, of increasing government control.
Now public health data can be even fuzzier and more debatable than cost inflation and enrollment numbers. But even with lower-than-hoped-for enrollment figures overall, we should still be able to see some of the happy consequences, at some point, if Klein et. al. are right: Looking back from 2020 or 2025, certainly, there should be some kind of disjuncture between U.S. health outcomes pre- and post-Obamacare (maybe a reversal of this trend, at the very least?), and some kind of outcomes gap should open between states that implemented the law fully and states that refused the extra Medicaid dollars.
So here, too, I’m curious what liberals expect to see, what they’ll count as vindication, what would disappoint them, and what kind of results they think will be sufficient to prove that Obamacare is, in fact, a lifesaving success.
And then for my own part, I’ll lay down this marker for the future: If, in 2023, the uninsured rate is where the C.B.O. currently projects or lower, health inflation’s five-year average is running below the post-World War II norm, and the trend in the age-adjusted mortality rate shows a positive alteration starting right about now, I will write a post (or send out a Singularity-wide transmission, maybe) entitled “I Was Wrong About Obamacare” — or, if he prefers, just “Ezra Klein Was Right.”