During his speech to Congress Tuesday night, President Donald Trump reiterated his criticism of the Affordable Care Act, calling the health care law a “disaster.”
"Obamacare is collapsing, and we must act decisively to protect all Americans. Action is not a choice, it is a necessity," said Trump.
The President went on to lay out five basic principles he’d like to see in a reworked health care system, including continued coverage for people with pre-existing conditions, more flexibility for states in administering Medicaid, and the ability of insurance companies to sell policies across state lines. Trump said the overarching goals for a replacement law must be to “expand choice, increase access, lower costs, and at the same time provide better health care.”
As GOP lawmakers work within Trump’s guideposts to hammer out a replacement of Obamacare, the successes and failures of the Affordable Care Act on those three fronts -- choice, access and cost -- will also shape policy decisions. In New Hampshire, the health care law has had mixed results in those areas.
Choice: A Rocky Start
For the vast majority of New Hampshire residents, the Affordable Care Act had little impact on health care choice. That's because most people in the state obtain their coverage through their employer (61%), or through government-run programs like Medicare and Medicaid (27%).
However, for people who by their own health insurance, the ability to choose a plan was severely limited when the Affordable Care Act launched in 2014.
Initially, Anthem Blue Cross was the only insurance company to offer policies through the New Hampshire marketplace. Further frustrating consumers, Anthem’s plans included a limited number of hospitals and doctors, meaning many people were not able to keep their current health care providers.
But in later years, competition increased, with five companies selling policies in 2015 and 2016, and this year, four insurers are offering plans, providing consumers with dozens of policies to choose between.
Access: A Surge in Coverage
What the President means by “increased access” is open to some debate. If we look at just a top-line number such as how many people have health insurance -- that is, they are able to access it and pay for it -- the Affordable Care Act has had a huge net-positive impact.
Nationally, an estimated 15-20 million more people have insurance today who didn’t before the Affordable Care Act became law. In New Hampshire, the number of uninsured residents has fallen from an estimated 151,000 people (11% of the population) to 68,000 (5%).
The reasons for this growth in coverage are two-fold. First, the Affordable Care Act requires people to have insurance (the individual mandate), or else pay a hefty fine. And second, the federal government chips in with subsidies to make plans more affordable for most middle-income consumers.
Another way to determine "access" is by measuring if people see a healthcare professional when they need care, and a telling statistic is the number of uninsured residents seeking treatment at hospital emergency rooms. Before the law, it was common for people without health care to show up at expensive emergency rooms, either because they put off needed primary care, or because they had no other health care options.
Data from the New Hampshire Hospital Association show that since Obamacare, the number of uninsured people seeking care at ERs in New Hampshire has fallen sharply. Between 2013 and 2016, there was a 45% decline, which analysts say reduces costs across the healthcare system.
Cost: A Spike Nationally, a Reduction Locally
Trump last night highlighted the surging costs of individual insurance policies, including in Arizona, where some premiums more than doubled between 2016 and 2017. There were also huge spikes in cost in Minnesota (55%) and Oklahoma (67%), among other markets. On average, Obamacare rates jumped 25% this year, before factoring in tax subsidies.
For opponents of the law, these price increases make a compelling case that Obamacare has done little to make care affordable.
In New Hampshire, it’s been a slightly different story. The cost of a mid-tier health plan rose by only 2% this year. And since the Affordable Care Act marketplaces launched in 2014, monthly premiums have actually fallen. A 40-year old resident would pay $267 per month today, compared to $289 per month in 2014.
And that’s just the sticker price: not included are the federal subsidies that most people qualify for.
Another quantifiable cost is Medicaid Expansion, which New Hampshire has agreed to through 2018. Roughly 50,000 low-income people are currently enrolled, and so far, the Federal government has covered all the costs of that health care.
That generosity is about to expire, however. States starting in 2017 have to chip in for more of the costs.
Estimates right now put the bill for expanded Medicaid in the state at just under $1 billion for the federal government, and for New Hampshire, at around $44 million over the next two years. However, in a slightly unusual arrangement, New Hampshire health insurance companies and hospitals are vowing to pick up that tab, not taxpayers, although those costs will in part be passed along to consumers.
Adding It All Up
Clearly, people can pick and choose the statistics that best serve their political leanings or their experience with the health care law. If you don’t ideologically believe that the federal government should have a heavy hand in health care, you aren’t going to like Obamacare, and can point to rising costs as a prime example for less government intervention.
If you think the healthcare marketplace was exclusionary and inefficient before the ACA, you can point to gains made in the number of people covered as proof that regulations help level the playing field and benefit consumers.
One simple fact both sides can agree on is that choice, access, and cost are all interrelated: and that makes it hard to craft health care policies that will improve all three.