On the Friday before a long Fourth of July weekend in 1966, Medicare began covering 19 million elderly Americans. Among the government’s worries: whether enough hospitals had eliminated separate wards for whites and blacks, a condition for taking patients through the new federal insurance program. “Medicare will succeed—if hospitals accept their responsibility under the law not to discriminate against any patient because of race,” President Lyndon B. Johnson said at the time.
Today begins the biggest expansion of health insurance since Medicare. According to the Congressional Budget Office (PDF), an estimated 7 million Americans will buy private health plans through the new online marketplaces known as insurance exchanges, which are now opening nationwide. That number is expected to more than triple in the years ahead.
It could be a bumpy launch, with technical problems and public confusion. Here are four big things to keep in mind as partisans on each side rush to render verdicts on the law’s success or failure:
1) The Affordable Care Act won’t expand coverage overnight. Medicare automatically helped millions of seniors with their hospital bills a year after it was signed. The ACA is more complex, and it won’t expand coverage as quickly. The law relies on a combination of incentives for people to buy insurance, marketplaces to shop for plans, and regulations to keep those markets functioning. It may be tempting for healthy people to skip buying insurance next year: The penalty for not complying is just $95, or 1 percent of income, whichever is higher. That ratchets up significantly in the next two years, to $695 or 2.5 percent of income. Expect more people to enroll as the penalties increase.
2) More states may come around. Almost half the states wanted nothing to do with Medicaid, which uses a combination of state and federal money to provide basic health coverage to poor families, when the program began in 1967, according to the Kaiser Family Foundation. Three years later, nearly every state had signed on. (Alaska joined in 1972 and Arizona did in 1982.) The Affordable Care Act is intended to expand Medicaid to encompass some low-income people who don’t currently qualify—for example, a family of four earning up to $31,322. Though about half the states are sitting on the sidelines, they may decide to expand Medicaid in the years ahead.
3) Glitches are inevitable, but they’ll get sorted out. Republicans point to delays and software problems as evidence that the Affordable Care Act is not ready for prime time. There’s a precedent for this: the GOP-led expansion of Medicare drug benefits a decade ago. In the first week of the new plan, patients were turned away from pharmacy counters. Some states declared public health emergencies and President George W. Bush ordered insurers to approve patients for a month’s worth of drugs for $5 while authorities sorted out the confusion.
4) The window for trying to undo the law is now closed. Opponents of Obamacare may not be ready to admit it, but the fight is over. Even with a government shutdown, the exchanges will still open. Their funding isn’t covered by the spending bills Congress halted. And, as Obamacare foe Senator Ted Cruz (R-Tex.) has said, once people begin to get insurance and subsidies through the Affordable Care Act, the law will be impossible to undo. “If we don’t do it now, in all likelihood, Obamacare will never, ever be repealed,” he told Sean Hannity.
The open question for the Affordable Care Act is whether its opponents will eventually accept it or continue to fight. Here, history may not be a guide. On the first day of Medicare, President Johnson described the program in an address to the nation. It was “a test of our willingness to work together,” he said. “In the past, we have always passed that test. I have no doubt about the future.”
