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How to measure Obamacare success

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It's too soon to pass judgment. But reporters can keep the debate honest and focused on the law's core goal


Obama Selling ObamacaRE
(image by Columbia Journalism Review)


A woman I'll call Gina, a 58-year-old hairdresser and Manhattan resident, is one of more than 587,000 New Yorkers who had completed applications for coverage in the New York insurance exchange as of last week, according to a press release from the state. But, like more than 250,000 of those people, she hadn't yet enrolled in a plan--though not for lack of trying. On her most recent attempt to navigate the website she spent nearly three hours trying to compare policies, but found it impossible to make an apples-to-apples comparison for several plans she was considering. The details insurers offered were so skimpy, she gave up in disgust. "I might save $150 [compared to what she was paying under her existing policy] but I am not confident about what these plans are offering me," she said. "They are not disclosing the real information you'd want to know. I am not going to take a leap of faith because the numbers look a little better, but not a lot better." She put shopping on hold.

At this still-early stage in the Obamacare story, is Gina's experience part of a "success" narrative because she completed an application and might even get cheaper coverage? Or is she part of a "signs of failure" storyline, because like 44 percent of signed-up New Yorkers, she hadn't actually bought insurance on the exchange and she was frustrated by the process? Those questions bring up others: How do we capture the "big picture" of a story that will unfold for several years? What would Obamacare success look like, and what metrics should we use to measure it? And since it will likely still be years before we can render an informed judgment on the program's efficacy at meeting its goals, and there are lots of incremental stories to write in the meantime, how do we cover those stories without passing on the agendas of one side or another in the Obamacare message war ?

Press coverage from a recent New York State Senate hearing shows how many shades of Obamacare gray there are, and how advocates and politicians on both sides can seize on particular data points. The Associated Press article quoted Donna Frescatore, executive director of the state's insurance exchange, calling the exchange launch an "overwhelming success"--and backing it up by noting the more than 300,000 New Yorkers who had bought a policy. But the same article also quoted Republican lawmakers noting only about 76,000 previously uninsured state residents had enrolled in a policy through the exchange, out of an uninsured population of 2.7 million. Of course, some of those uninsured folks are now presumably covered under New York's federally-supported Medicaid expansion--and isn't that a success, under the law's provisions?

Covering the same hearing, Anemona Hartocollis of The New York Times led with a different measure : the share of young adults in the exchange pool, which some (though not all ) observers see as key to a sustainable risk pool and stable premiums. Thirty percent of New York's enrollees are under 35, Hartocollis reported, and Frescatore was ""pleased with that as a very early indication' that the exchange was working." The ACA-boosting Times editorial board was pleased , too--but a critic might reply that even if insurance costs do stay under control in 2015, that's not necessarily a sign that the law is on good footing for the long haul.

Will New York's exchange be a success? The short answer is, it's too soon to say. That sounds wishy-washy, but we can identify the right questions to ask, and start pressing them hard. Several years ago medical journalist Gary Schwitzer created a series of questions reporters should pose when writing about new medical interventions. John Lister, a professor of health policy at Coventry University in the UK, adapted Schwitzer's framework for writing about health policy: Who's claiming success (or failure) and are their conflicts of interest explored? What's the evidence for the claims? What are the downsides, or in the case of numbers, what's the context and the nuance?

That last one is especially important, as Washington Post factchecker Glenn Kessler showed in mid-January . An announcement by the pro-Obama group Organizing for America that 6 million people had signed up for coverage under the reform law depended on the claim--which had been widely reported--that 3.9 million people had been added to the Medicaid rolls. But as Kessler showed, that figure had essentially no meaning for coverage expansion--it "tells you almost nothing about how the Affordable Care Act is affecting Medicaid enrollment," he wrote. In fact, "No one really knows" how many Americans are newly on Medicaid, at least not yet.

I phoned Harvard pollster Robert Blendon for his take on the question of how we should cover success. It's tricky, he said, but it's also straightforward--amid all the goalpost-shifting and overpromising, the core purpose of the Affordable Care Act was to offer more people insurance coverage. That's like using the all-important metric if you're covering a medical study: Did the study achieve its end point, its goal?

The number to focus on, Blendon said, is "the share of uninsured in your state who were uninsured prior to January 1 and who have signed up for a policy through the exchange and actually paid the premium. As for Medicaid, the magic number in any state is how many new enrollees are in the program. It doesn't matter whether sign-ups come from people previously eligible who've come out of the woodwork to enroll or from those who gained coverage under the expansion."

If these numbers are going up in a big way, it's a win for the law at a fundamental level (though there are important questions about narrow networks, out-of-pocket costs, stability of the plans on offer, and more). If they aren't, it's a loss. It's really a simple calculation. Getting good numbers is the hard part. And since we still have only the most preliminary numbers, in most cases it's hard to say with any confidence what they mean. The people expressing confidence are the partisans and advocates, many of whom have their minds made up before they see the numbers.

What can reporters do now? Call out those too-quick judgments, and show what they leave out. Get educated about the smarter predictions of long-term success or doom , and check back on how they're holding up when important signposts pass. Talk to as many ordinary people like Gina as possible, insured and uninsured, about their experience with the law. And clue in readers and viewers that the story is far from over.

 

Trudy Lieberman, a journalist for more than 40 years, is a contributing editor to the Columbia Journalism Review where she blogs about health care and retirement at www.cjr.org. Her blogposts are at http://www.cjr.org/author/trudy-lieberman-1/ She is also a fellow at the Center for Advancing Health where she blogs about health at (more...)
 

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What reporters "can do now" is to report on just w... by S. Juniper on Wednesday, Jan 29, 2014 at 7:41:06 AM
Are you saying that your grandson is better off re... by Jerry Wesner on Wednesday, Jan 29, 2014 at 11:03:02 AM
Oh don't worry. If your grandson has no property ... by Textynn N on Wednesday, Jan 29, 2014 at 8:57:48 PM
Let's not loose sight, lest we succumb to the num... by Art Costa on Wednesday, Jan 29, 2014 at 7:54:39 AM
What I heard here was "The government application ... by Jerry Wesner on Wednesday, Jan 29, 2014 at 11:00:41 AM
Wait till they decide you are too old for many tr... by Textynn N on Wednesday, Jan 29, 2014 at 9:01:10 PM
Since the main purpose of Obamacare is not to ensu... by Jim Kavanagh on Wednesday, Jan 29, 2014 at 2:41:33 PM
Wall street owning healthcare, running Welfare, a... by Textynn N on Wednesday, Jan 29, 2014 at 8:50:56 PM
What if the "big picture" of Obamacare is to keep ... by Jill Herendeen on Thursday, Jan 30, 2014 at 8:38:24 AM