One last round of website crashes, jammed call center lines, frustrations and delays marked the end of Maryland's first open enrollment period under the Affordable Care Act and ensured that the launch of the Maryland Health Connection will go down as one of the most expensive failures of governance in the state's history. A full accounting of how Maryland failed so badly while other states handled open enrollment with relative ease can't come soon enough.
That said, Obamacare is not a website. It's a complex set of reforms designed to expand health insurance coverage and eliminate many of the flaws of our previous system, such as lifetime limits on benefits or the inability of those with pre-existing conditions to get coverage, while at the same time taking steps to rein in the explosive growth in health care costs. Though we cannot excuse or forget the problems with the website, which the state is poised to ditch in favor of technology that proved successful in Connecticut and elsewhere, it's important to remember that it was just a means to an end. Our focus must now shift to evaluating whether the law itself works.
The Obama administration cheered the news that enrollment in private plans through health exchanges was on track to exceed the initial target of 7 million by Monday night — beating the revised goal of 6 million, which was set after the bungled launch of healthcare.gov. But health insurance markets are state-based, not national, and what matters most to Marylanders is what's happening here.
On the plus side, the state had signed up nearly 270,000 people for insurance as of last Friday, exceeding a goal of 260,000 people. The final tally after the weekend may come close to 300,000. Most of that, 220,000 people, reflected enrollment in Medicaid, the cost of which will be almost entirely picked up by the federal government. Critics of Maryland's implementation of Obamacare have acted as if Medicaid expansion doesn't count, but in reality, it means hundreds of thousands of low-income adults who didn't have health coverage of any kind now do.
The effects of that are already being seen. Backers of the law held an event at Healthcare for the Homeless in Baltimore to highlight individual stories of people who have been helped by the law, and to release a telling statistic: Before the ACA went into effect, only about 35 percent of Healthcare for the Homeless' clients had insurance; now it's about 84 percent.
On a broader scale, the Medicaid expansion meant that the state was able to move about 96,000 people who had been enrolled in a limited, primary care program for adults into full coverage. On Friday, Gov. Martin O'Malley released the results of a study by Maryland's Health Services Cost Review Commission showing that those 96,000 people had run up $164.4 million in uncompensated care at the state's hospitals in fiscal 2013, the last year for which they lacked full insurance. That matters to every Marylander because the costs of uncompensated care are passed on to the rest of us through higher hospital rates and, consequently, higher health insurance costs. It's entirely probable that the same would hold true for the other 124,000 people who signed up for Medicaid during the last six months.
Though taxpayers foot the bill for Medicaid, the shift should ultimately work to reduce total costs by giving more people access to primary and specialist care, chronic disease management and other benefits that will keep them healthier and reduce instances of catastrophic (and expensive) hospital care.
What will bear close watching is enrollment in private plans through the health exchange. The state had initially projected that it would sign up 150,000 people in private plans, though officials later said that had been the result of erroneous calculations and that the true figure should have been 75,000. It stood at just under 50,000 as of Friday and had jumped to 63,000 by the end of the day on Monday, with about 10,000 more pending applications. An unknown number of additional people signed up directly with insurance companies.
What happens next will have a greater bearing on the ultimate success or failure of the Affordable Care Act than the balky website has. Will those who signed up make their payments and keep their coverage? And what are the characteristics of those who joined the pool? Are they disproportionately sick — and hence motivated to get coverage — or are younger and healthier people signing up? Will the availability of primary care help people stay healthier and, thus, reduce the growth in overall health spending? Will experiments authorized under the law — like Maryland's new Medicare waiver that moves hospitals away from the fee-for-service model — take root and expand? It will take years to get the answers to those questions, but they will ultimately determine whether the Affordable Care Act lives up to its promise.
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