With the first of the year just days off, the full impact of healthcare reform is poised to kick in but whether it will achieve U.S. President Barack Obama's vision of affordable protection for all still is an open question.
Obama's signature Affordable Care Act, aka Obamacare, was designed to enable a large proportion of the 48 million Americans without health insurance to obtain coverage but has been plagued by missteps since it was signed into law nearly four years ago.
First there was the realization its longterm-care provision was unworkable. Then there were claims the medical device tax would cost jobs and the postponement of the provisions concerning large-employer reporting requirements. Members of Congress and their staffs were able to win special subsidies. More recently there was the botched rollout of the health insurance marketplace website and the cancellations of millions of policies that provided catastrophic insurance but did not meet the ACA's threshold requirements. And for those who make just a little too much money to qualify for government subsidies, premiums can be anything but affordable, approaching 20 percent of income, a New York Times analysis indicated.
As the year drew to a close, deadlines for those without employer-provided insurance to sign up through the marketplace for policies effective Jan. 1 kept slipping and fears grew that those who managed to sign up weren't really covered because their information was not properly transmitted to carriers.
Originally, consumers faced a Dec. 15 deadline to sign up for coverage effective Jan. 1 -- but that deadline was extended to last Monday after problems with HealthCare.gov surfaced. Then the White House added a 24-hour grace period because of heavy traffic at the last minute and before that was up added a "special enrollment period" for those who missed the deadline.
Yet Obama hailed the website, boasting it was now handling the necessary volume of sign-ups without crashing repeatedly and opponents vowed new assaults on the law in 2014.
By Christmas Eve, more than 1 million people had signed up. The administration had been hoping for at least double that figure.
Sen. Chuck Schumer, D-N.Y., downplayed the problems, recently saying there always are problems with complex legislation, likening "drafting errors" to bugs in software and saying the ACA will get fixed, one way or another.
Sen. Joe Manchin, D-W.Va., has suggested a "transitional year," putting off penalties against individuals who do not obtain coverage to allow the marketplace to adjust and flaws in the law to be fixed.
But University of Chicago Booth School of Business finance Professor John H. Cochrane said fixing the law is not enough.
In an op-ed piece last week published in the Wall Street Journal, Cochrane said rather than the current mash-up or adopting a single-payer system -- something some opponents of the ACA fear is inevitable as a result of the current law's perceived unworkability -- competition should be opened further.
Cochrane envisions a system where people buy health insurance when they are young with the guarantee premiums never will skyrocket, coverage cannot be canceled as a result of illness and policies are portable from job-to-job and across state lines. He said such a system "can deliver high quality, technically innovative care at much lower cost and solve the pathologies of the pre-existing system."
"While economically straightforward, liberalization is always politically hard. Innovation and cost reduction require new businesses to displace familiar, well-connected incumbents," Cochrane wrote. "Protected businesses spawn 'good jobs' for protected workers, dues for their unions, easy lives for their managers, political support for their regulators and politicians, and cushy jobs for health-policy wonks. Protection from competition allows private insurance to cross-subsidize Medicare, Medicaid and emergency rooms."
The ACA is supposed to have an impact on medical costs. In the third quarter, however, revised figures indicate spending on healthcare services grew at an annual pace of 2.7 percent, not the originally estimated 0.9 percent.
With higher deductibles and co-pays, the ACA is supposed to turn Americans into more discerning medical care shoppers. But the question of how they're supposed to do that is unresolved since few doctors, hospitals and other medical providers have price lists, and queries are often met with no specifics and answers indicating the prices vary by insurance company and policies within those companies.
The latest Kaiser Foundation tracking poll finds 61 percent of the 1,206 adults polled Dec. 10-15 said they think the ACA caused many people to lose coverage and 57 percent said it increased the federal budget deficit.
Only 34 percent said they had a favorable view of the ACA while 48 percent gave it a thumbs down. Of those who have a negative view of the ACA, 23 percent cited costs, 18 percent opposed the individual mandate, 13 percent objected to government involvement, 7 percent cited the sign-up process, 7 percent objected to subsidies, 6 percent decried policy cancellations and 6 percent didn't understand what the law is supposed to do.
Forty-two percent said the ACA should be repealed while 43 percent want to see it expanded.