Obamacare hit the 6 million mark on Thursday, giving the health care law's supporters and detractors a concrete landmark to grade its success on. The thing is, that number means something different to every state. As The New York Times explains, how well Obamacare works depends on where you live. After going over state-by-state enrollment numbers and interviewing consumers, the Times found that "for consumers at least, the state of health care under the national law depends almost entirely on where a person lives." As we all begin our premature assessments of Obamacare's success, we should keep that in mind.
There are a lot of problems with that 6 million number. It doesn't tell us how many people have paid their premiums, or how many have enrolled off the exchanges. It doesn't tell us how old or young or healthy those enrollees are. More importantly, the number suggests the law's success is spread evenly. Politico's Obamacare report card, for example, grades the law's premiums on a national level. "So is the Affordable Care Act affordable? It is for some people, but certainly not for everyone," David Nather writes. "That means the law needs two grades, one for the target groups and one for the spillover effects."
It actually needs at least 50 grades. The ongoing narrative that the overall percentage of young people plus the overall enrollment number will tell us how low premiums will be. That logic is flawed, and "the equivalent of judging the local weather from national averages," the Kaiser Family Foundation's president, Drew Altman, wrote this week.
Several factors have affected those enrollment rates in different states. It's been noted that some state-run exchanges don't work as well as others (or work at all), but even in those states outreach has generally been more robust. The surest sign on the success of Connecticut's enrollment site is the fact that it decided not to offer a special enrollment period. States that have expanded Medicaid have also seen more enrollment. Meanwhile, states like Florida and Texas, where millions of uninsured Americans live, have either banned enrollment navigators or made it extremely difficult to get certified.
There are also the standard, pre-Obamacare reasons that insurance costs more in certain places. Rural Georgia — where many residents have high rates of obesity and heart disease and there are not a lot of doctors or hospitals — premiums are more expensive. And Colorado ski towns, which are isolated and more expensive to live in that the rest of the state, are also experiencing higher premiums, and will continue to do so regardless of how many people sign up in other parts of the country.
Politically, 6 million is a good number — it means the administration met the Congressional Budget Office's lowered expectations, and it reads like a comeback story for Democrats. But how that plays out in the nation's poor rural counties and states like Texas — where opposition is so strong, some people think Obamacare has been banned — is what will really matter.