October 1, 2013, is not the most important date in Affordable Care Act implementation history.  The most important date is November 4, 2014, when the next members of the House of Representatives and 1/3 of our senators are elected or re-elected.  The nation’s collective judgment about the ACA will be on the ballot then even more than it was in the Presidential election year of 2012 and will be again in 2016.

October 1, 2013 is an important milestone for the progress of health reform, for it ushers in a new era of insurance market rules, rules that are considerably more in the consumer’s favor.  Not completely, and not costlessly, but more in the consumer’s favor than ever before.  For the first time in our nation’s history, insurers can neither refuse to sell to someone with an existing health condition nor charge them more than a perfectly healthy person of the same age.  For the first time in our nation’s history, lower-income working people without access to tax-subsidized employer-sponsored insurance (which most people reading this blog post have) will be eligible to buy relatively comprehensive insurance at relatively affordable prices (by all accounts at least some premiums in every market are way lower than feared and actually cheaper than a typical group policy today), due partly to the competition engendered by the new market rules and partly to new income-based subsidies.

For the first time in our nation’s history, a combination of federal and state policies (in some states) will make it possible for every American citizen to afford decent health insurance and thereby greatly increase equity in access to quality and effective care, which should ultimately enable us to abolish the fear of financial ruin from out-of-pocket health costs and to become a healthier nation.  These are all very big deals in the evolutionary improvement of our democratic republic.

It has become easy and common to predict that some of the new marketplaces’ enrollment and eligibility-determination systems will not be perfectly ready for prime time on October 1.  There will be more telephones and pencils and paper pads used that day, and possibly for weeks end even months afterward, than perhaps anticipated 2, 12, or 36 months ago.  We need to take a deep breath and remember that this is OK.  What matters is not that 35 million-plus uninsured Americans are suddenly enrolled in some insurance plan on October 2, 2013, or even January 2, 2014.  What matters on the coverage front, in my view, are the values that will flesh out the following state-specific table at each of the next four October 1s, starting in 2014:


Some states, to their enduring shame but by choices made by their elected representatives, will have a conspicuous zero in columns 4 and 5, at least in October of 2014.  The single number that will matter most to the larger world outside the marketplaces per se will be the premium growth rate in the last column, for the ultimate cost of the ACA to federal taxpayers will be highly correlated with that growth rate.  The numbers that will matter most to those who care most about coverage expansion will be columns 3 and 5.

I predict the effectiveness of the ACA can and will be fairly judged on all values in these tables in each ‘election’ October, for some time to come.  Stay tuned.  This is going to be a long and winding road to judgment.