Despite turmoil, health coverage rises in United States ======================================================= * Cal Woodward President Barack Obama’s historic health care law has survived one cliffhanger Supreme Court decision, but will confront another in March. It emerged from epic political battles, only to be thrown into the thick of more fights in a new Republican-controlled Congress this year. It survived start-up glitches that made the law a national punch line — even Obama cracks jokes about it — and now enters a rocky adolescence. But a funny thing has happened on the way through these trials and turmoil: the number of uninsured Americans has dropped, substantially, finally. By various measures, the law is helping to shrink the central disparity of the American health care system: the divide between people with and without health insurance. Other pressing questions about the quality of care and affordability of insurance under the hopefully named Affordable Care Act (ACA), nicknamed Obamacare, remain problematic. This is shakeout time for the ACA. New, federally mandated insurance marketplaces, set up in each state primarily to offer insurance policies to people who don’t get health coverage at work, are in their second enrolment season. It’s the first chance to see how attractive the new insurance options are proving to be for those who signed up in the messy debut and what effect the entry of millions more people into the insurance market is having on rates. It’s gone better than last year, when website nightmares prompted Obama, in a mix of levity and exasperation, to declare, “That’s where Disney got the idea for *Frozen*,“ and to say he’s taking the country “to health in a hand basket.” In 37 states where the federal government runs the new markets, more than 6.6 million people so far have enrolled in coverage for 2015. Several million more have done so in states that operate the markets themselves. Altogether, Gallup surveys find a sharp reduction in the uninsured, down recently to 12.9 per cent of the adult population from 17.1 per cent a year earlier. At least 10 million Americans have gained coverage. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/187/4/246/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/187/4/246/F1) In the past year, the percentage of US adults without health insurance has decreased from 17% to 13% under the Affordable Care Act. Image courtesy of REUTERS/Lucy Nicholson It’s no wonder coverage is up. Generous subsidies are offered to most marketplace customers. And Americans who go without insurance now are fined. Still to be seen is whether requirements and incentives coming to job-based health plans will expand or shrink that crucial source of insurance. Obamacare is clearly sinking roots, but it could still be yanked out of the ground. In 2012, the Supreme Court narrowly upheld the heart of the ACA: the requirement to obtain coverage or pay a penalty. Now, the court will decide whether the federal government can continue to subsidize premiums in states that declined to set up their own marketplaces under the law. A negative ruling could quickly upend Obamacare’s superstructure and erase the “affordable” part of the whole enterprise. The case is expected to be heard in March and will be decided before the end of June. Republicans now command a majority in both chambers of Congress, making their continual threats to roll back Obamacare more than empty bluster. Even so, Obama can stop them with a veto. Some elements of the law, however, such as a tax on medical devices, could fall. Eric Dezenhall, who helps corporations and well-known people deal with scandal, has watched Obamacare progress from a basket case to something rather tedious. “While I don’t think people are running around wearing Obamacare T-shirts with matching pompoms, it’s a subject that has receded,” he says. “From where I sit, Obamacare is in the boring implementation stage, not the look-at-that-terrible-website stage.” “When a dog chases a rabbit and the rabbit gets away,” he adds, “the rabbit doesn’t get to eat the dog, he just gets to keep being a rabbit. So it is with crisis management. Obamacare gets to chug along as a law, so there’s your win.” ### More News online To read more *CMAJ* news articles, visit [cmaj.ca/site/home/news.xhtml](http://cmaj.ca/site/home/news.xhtml)