Millions of people got insurance through the exchanges since they went into operation in October of 2013 (millions also got coverage through Medicaid). But the year ended with doubt. Republicans, largely opposed to the Affordable Care Act, won both houses of Congress, and the U.S. Supreme Court said it will hear a case that could derail the exchanges altogether.
Kevin Counihan began 2014 running Connecticut's health exchange, one of the most successful state. He was tapped in August to leave Connecticut and run the federal insurance marketplace, HealthCare.gov. He says that serving consumers is a top priority. The good news for him is that bar is pretty low. At its launch in 2013, HealthCare.gov began by failing. Now, things are looking up.
"A year ago, when somebody would come on HealthCare.gov they would have to walk through 76 screens in order to complete their application. That's been reduced now to 16," says Counihan.
He points to other successes, too. There are more insurers in the marketplace. People renewing could have a fairly easy time of it, since their applications have 90 percent of their information already entered. And millions of people got in touch before Dec. 15, which was the deadline for those who wanted coverage beginning Jan. 1, 2015.
"We had an extraordinary weekend," says Counihan, referring to Dec. 13 and 14. Call centers fielded 1.6 million calls, he said with over 1 million calls on Dec. 15. "And the next day, that Tuesday, the 16th, at our morning stand-up meeting, the first thing we asked was, 'What are the service issues?' No consumers had called in with service issues," he says.
Counihan says he hasn't had time to worry about the broader existential threats to the Affordable Care Act. He's just focused on making it run.
"The basic premise is that having more people insured than fewer is better for both the people and the country because it provides the best way to improve people's lives and also to better control health care costs," he says. "I think it could be described really as probably the most significant social program in 50 years — since the creation of Medicare and Medicaid."
That's one way of looking at it. Here's another, from Cannon: "It's amazing what you can accomplish when you're willing to break the law."
Cannon is the director of health policy studies at the libertarian Cato Institute and has long opposed the Affordable Care Act.
As he sees it, the Obamacare train may be running on time, but it never should have left the station to begin with. He says the subsidies are only meant for state-based exchanges. Meaning, the subsidies the government is paying to consumers who buy their insurance through HealthCare.gov are not in the law. By paying those subsidies, he says, Obama is breaking that law.
Cannon concedes that millions of people have gotten subsidies. And there's no avoiding the fact that the exchanges are up and running, and there are more insurers in the market creating competition. But he says it's all flawed.
"None of this would have happened if not for those illegal subsidies the president is offering in the 36 states with federal exchanges. There would be no exchanges, there would be no competition, there would be no insurers participating. None of this would have happened if the president were following the law. There would be no successes if the president had followed the law."
Cannon has spent the last few years arguing that the subsidies are a problem. Soon the Supreme Court will hear the case.
"By mid 2015, the Supreme Court could rule that the administration has been breaking the law and, at that point, some five million people who the administration has enrolled in health insurance through HealthCare.gov will see their premiums quadruple, see their tax liabilities increase by thousands, they could see their plans disappear," he says.
While that may be disruptive, Cannon says it wouldn't be nearly as bad as letting the subsidies continue. That, he says, would give Obama and all future presidents permission to govern beyond the limits of the law.
But Cannon cautions against getting too caught up in how the justices will rule. Even if Obama wins the legal argument, with Republicans in charge of Congress, the political fights will continue.