A CBO Full of Surprises: Obamacare Will Insure 2 Million Fewer in 2014

Obamacare will insure 2 million fewer people in 2014 than previously reported.  That number is in a new report just released by the Congressional Budget Office (CBO).

That may come as a surprise to you.  But it isn’t the biggest surprise in the report for me.  I’ll explain why later. 

First, let’s review the new numbers.

Last May, the CBO estimated that seven million people would sign up for insurance through exchanges this year.  That number is not a surprise – it has been reported widely in the media.

It also estimated that nine million previously uninsured people would be enrolled in Medicaid or CHIP.  In other words, a total of 16 million people would obtain coverage this year through Obamacare.

But last week, CBO released updated estimates.  It now says that only 6 million will sign up through the exchanges this year, and only 8 million will enroll in Medicaid or CHIP. 

Because some of the people who would have signed up are already insured, that means that the number of uninsured people will grow by 1 million over the CBO’s previous estimate.

Is that really a surprise?

It has been evident for some time that getting 7 million people to sign up for insurance through the exchanges was an ambitious target.  And the early glitches sure didn’t help.  But enrollments have been going much more smoothly lately, and reaching 6 million would still be impressive.

Also, taking into account the new enrollments in Medicaid and CHIP, the overall number of uninsured would still be reduced this year by 13 million.  That would reduce the total number of uninsured people from 58 million in 2013 to 45 million – halfway to Obamacare’s 2016 full-implementation target of 31 million.

That is still a pretty good result, and about what could have been expected.

And there is a little more good news on the fiscal side.  Lower enrollment numbers mean a little less spending for ACA each year, and in a program this big, that comes to $18 billion saved over ten years.

That would be enough to fund the prevention fund again, but I guess we shouldn’t go there.

So where’s the surprise?

The first is, of course, could be in the perception.  Much as the headline from the CBO report last week that Obamacare would cause the loss of over 2 million jobs was pretty surprising, another headline that it has fallen 2 million people short of its 2014 insured targets could be just as shocking. 

Of course, last week’s headline didn’t mention that the jobs “lost“ come about largely from among people who feel too sick to work, and who hold onto a job solely because they need the health insurance that comes with it.   The next headline may also not mention that the newly insured people also will come from among those who perceive that they need health insurance the most.

The second is also in the perception.  If Obamacare falls short of its targets, and those targets are recast as promises, then this will be perceived as another Obamacare promise broken.  People always seem surprised when they hear about politicians breaking promises, and they often make them pay at the polls.

But what may be the biggest surprise of all in the new numbers? 

It is this: that Obamacare is working almost exactly as it was intended, and appears to be having almost exactly the result that was intended. 

We are actually getting from the Affordable Care Act almost exactly what the President and Congress said we’d be getting way back in 2010.  And whether you like the law or not, this does suggest that members of Congress were a whole lot more knowledgeable about what they were voting for back in 2010 than most people give them credit for.

In other words, this law was put together out in the open.  The provisions in it were put together in a thoughtful way.  And those who made promises about what it would do were, in fact, telling the truth.  

And while a few of us may be surprised by how it has affected us personally, as a whole we all do know where we stand with this program.

I wish that were the case with all public policy initiatives. 

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

A Billion More Reasons to be Disappointed in this Congress

It was good news when Congress recently agreed on a budget for the first time in forever.  It was the product of compromise, and everyone expected to give at least a little. 

But when the details came out last week, it turned out that some had to give more than others.  And the ones who probably gave up the most were the people who have saved the greatest number of lives over the past century – the public health and prevention community.

Last week, the House introduced the FY2014 Omnibus Labor, Health, Human Services, and Education bill – one of twelve appropriations bills that will implement the FY2014 budget.  As the bill summary noted, the legislation includes $156.8 billion in discretionary federal spending for all these important areas combined. That is a big number, and comes to around $500 per person.  By comparison, Defense– which is often considered to be the other “big” area of discretionary spending – will get around $1500 per person.

But the disappointing number wasn’t the bottom line, which is $100 million below the FY2013 level.

It was that – to get to the bottom line – Congress has proposed to cut $1 billion from already-promised public health and prevention funding.

When the Affordable Care Act was passed in 2010, it had a price tag of around $1 trillion over ten years.  This wasn’t all new spending.  We were going to spend at least that much on health care programs whether the law passed or not.  What ACA did was to re-structure that spending.

Historically, public health and prevention have gotten about 3 percent of our health dollars.  And if ACA had continued to provide that share, then $30 billion would have been dedicated to public health and prevention.

But when the dust settled in 2010, the new Prevention Fund (which was once targeted for as much as $80 billion) was promised only $15 billion, or an average of $1.5 billion per year for ten years.  And even this more modest amount was described by Senator Tom Coburn (a physician) as “a slush fund” within two weeks of its passage. 

Congress has hacked away at this fund ever since.  Two years ago, it slashed $5 billion from it.  As I wrote at the time, this represented 6 percent of total public health spending in 2010, and would cost us over 13,000 lives.

This was beyond disappointing for anyone who cares as much about the health of the population as he or she does about health care.

But it did not stop Congress was disappointing us again this year.  Or from using some of the same hypocritical reasons for cutting prevention programs today as it has in the past.

The bill summary claims that the legislation “seeks to focus tax dollars on programs that are critical to the health and well-being of Americans, including disease prevention and research programs.”  But it appropriates a total of only $160 million of the bill’s $156.8 billion to the Prevention Block Grant.

That represents just one dollar for prevention block grants for every one thousand dollars of omnibus bill spending.

And just two sentences later, it announces that it will reduce “the Prevention and Public Health ‘slush’ Fund by $1 billion.”

The reason it gives for slashing the “slush fund” is “to prevent the Secretary of HHS from raiding these funds for Obamacare exchanges.”  That actually happened in 2013, as Sarah Kliff explained in a terrific Washington Post blog on the shrinking fund last April.

But Congress raided these same prevention funds in 2012 to pay for the so-called “Doc Fix” (i.e., to prevent a sudden 30 percent decrease in Medicare payments to physicians that was caused by an error in a reimbursement formula in place since 2002 that Congress has failed at least a dozen times to fix permanently).

Members of Congress, like everyone, expect to have water that is drinkable, food that is edible, air that is breathable, homes that are safe to live in, and outdoor spaces to relax and exercise in.  If they take care of themselves, they hope to avoid cancers, heart disease, and other chronic conditions.

They understand the connection between these things and public health and prevention funds.  They just choose to ignore it.

If you have been disappointed by this Congress in the past, you probably have your reasons. And if you care about prevention and public health, now you have a billion more.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/