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The Obamacare attack

In an election season rife with misinformation and outright falsehoods, is there any issue where voters are so thoroughly led astray as Obamacare? To hear Donald Trump describe the Affordable Care Act and the push to cover more Americans through private health insurance, it's a "failed health care takeover" and his vow to repeal it is "one of the single most important reasons" he will emerge victorious on Nov. 8.

Long ago, Republican strategists circled this week on their calendars. It's not only the final days before the election, but Nov. 1 also marked the beginning of the annual sign-up period for ACA health plans, and this year, a lot of customers — those who buy in the individual market — are facing substantial premium increases. Circumstances vary, but some people are seeing rate increases of 100 percent or more, and that's quite an "owie," as pediatricians like to say.

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But here's where that headline misleads. First, a relatively small percentage of Americans buy their health insurance through the individual market. The vast majority get it through their employers or other groups or through government programs like Medicare or Medicaid. And the majority of people who do purchase individual policies through the Obamacare marketplaces qualify for a subsidy, so any additional amount they must pay out of pocket may be quite small.

As a result, officials estimate that about 70 percent of Obamacare exchange customers can get minimum coverage for about $75 a month in out-of-pocket costs. Granted, these are low-cost plans with limited benefits, but they do meet minimum standards for medical coverage. Even those individuals who are facing sharper increases can blunt the impact if they shop around or reduce their level of coverage.

That's not to dismiss the genuine hardship some people face in paying for health insurance, some of whom are hit hardest not by provisions of the ACA but by their states' refusal to broaden Medicaid coverage. Indeed, the highest premium increases across the country were felt in states that opted out of the Medicaid expansion. And such a choice by states comes with a much higher bill than increased premiums — people without health insurance coverage are more likely to face serious illness or premature death than people who have it and use it.

Mr. Trump, who has been calling for a special session of Congress to "repeal and replace" Obamacare (without having a workable replacement) conveniently ignores the ACA's biggest success — 20 million more Americans with health insurance coverage. Today, less than 10 percent lack health insurance while overall federal spending on health care is down — about $2.6 trillion less over a five-year period than what was projected before Obamacare become law.

And that's not all. Because of the ACA, Americans can't be refused coverage for pre-existing conditions, children are allowed to be covered by their parents' health insurance until age 26, there are no lifetime caps on insurance claims, and premiums outside the Obamacare markets have stabilized at 4 percent annual growth. Odd, how those improvements don't tend to make it into Republican stump speeches.

Part of Obamacare's problem is that younger, healthier individuals aren't signing up for coverage; they'd rather risk the penalty. And so that leaves sicker customers in the pool, and as they make claims, insurance providers are forced to raise premiums to recoup their costs. As any insurance company will tell you, when the risk pool shrinks, bad things tend to happen.

There are any number of ways to fix these problems, but Republicans in Congress aren't willing to make the changes. They've put all their political eggs in the basket of repeal. Even the most fleshed-out GOP counter-proposal to date, the one offered by House Speaker Paul Ryan during the summer, is maddeningly vague on the details of what happens to Obamacare policyholders who now benefit from government subsidies.

No matter who wins next Tuesday, it's difficult to believe that the ACA is going to be repealed. That's simply not the nature of federal entitlement programs (Obamacare effectively being about half-entitlement). The far more realistic outcome is to pursue fixes that Republicans will find politically acceptable — increasing penalties for those who fail to sign up, perhaps, or extending subsidies to the most catastrophic medical cases. Failures in the Obamacare insurance market can be fixed if there's enough political will to do it.

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