What’s really happening with Obamacare

After receiving information about Health Care Reform, Paula Thornhill, 31, of Woodbridge, holding her daughter Serenity, waits for a relative to receive the same information as the Greater Prince William Community Health Center launched its education and enrollment services for the Virginia Health Insurance Marketplace on Tuesday, October 1, 2013, in Woodbridge, VA. In the background are Thornbill's son, Daniel, 2, Fatima Lopez of Manassas, and Roxana Hernandez with her son, Angel Rivas. The Center is the only agency certified by the Centers for Medicare and Medicaid Services (CMS) in Prince William County to enroll the public. (Photo by Jahi Chikwendiu/The Washington Post via Getty Images)

After receiving information about Health Care Reform, Paula Thornhill, 31, of Woodbridge, holding her daughter Serenity, waits for a relative to receive the same information as the Greater Prince William Community Health Center launched its education and enrollment services for the Virginia Health Insurance Marketplace on Tuesday, October 1, 2013, in Woodbridge, VA. In the background are Thornbill's son, Daniel, 2, Fatima Lopez of Manassas, and Roxana Hernandez with her son, Angel Rivas. The Center is the only agency certified by the Centers for Medicare and Medicaid Services (CMS) in Prince William County to enroll the public. (Photo by Jahi Chikwendiu/The Washington Post via Getty Images)

The Affordable Care Act, as you have no doubt heard, has a really flawed website. But here’s what else we know, a month into the implementation of one of the most controversial and far-reaching laws passed in decades.

1. Tens of thousands of Americans are getting health insurance

There is little comprehensive, nationwide data on how many people have signed up for insurance under the law. The federal government, which is completely or partly operating the health care markets set up under the law in all but 16 states, has so far refused to release enrollment statistics. Most states haven’t released full data either.

But there is clearly interest from Americans. The state of Oregon sent notices to its low-income residents in September, telling them they would be newly-eligible for Medicaid because of the federal health care law and that they could fill out a two-page form or call a phone number and be enrolled. More than 62,000 people in the state already responded in October and will have coverage under Medicaid starting on Jan. 1, according to state officials. In Kentucky, more than 31,000 people have been enrolled in either Medicaid or private health care plans through the state’s exchange, according to state officials. In Arkansas, more than 7,000 have enrolled through a Medicaid-like program it has created with funds under the law.

This data remains very preliminary. A person is not truly considered “enrolled” in a private health care plan until she has paid the first month’s fee, which many people still have not done since the insurance does not start until Jan 1. The Advisory Board Company, a D.C-based consulting firm that specializes in health care and higher education, estimates that about 150,000 have enrolled in new health care options under “Obamacare” in the states that are running their own health care exchanges. They have not yet estimated how many have enrolled in the 34 states who are reliant on the federal government for their exchanges.

It’s important to put 150,000 enrollees in context. That number does not include states such as California, which has released little data. And it’s far, far less than officials hope will eventually enroll. The Congressional Budget Office estimated earlier this year that by the end of 2014, 7 million Americans would be enrolled in new private health care plans under the law, while another 9 million would get coverage either through Medicaid and the State Children’s Health Insurance Program, a program for low-income children. The 9 million would include both people who are newly-eligible for Medicaid and people who were already eligible for Medicaid and SCHIP but had not enrolled and will do so now because of increased outreach by state governments.

2. Many of the poorest Americans are getting insurance

The health care law vastly expanded the number of people who are eligible to receive insurance under Medicaid, which had previously excluded millions of childless adults. Virtually all Americans with incomes below $16,000 or in families of four with incomes below $33,000 are eligible for Medicaid, except in the more than two dozen states who are opting against participating in the Medicaid expansion.

In the state of Washington, 42,000 of the 49,000 newly-enrolled people had low enough incomes to qualify for Medicaid, state officials told the Seattle Times.  Arkansas and Oregon have specifically and successfully targeted low-income people, while officials in Kentucky say a major chunk of their enrollees will be Medicaid recipients.

In this way, the health care law is working exactly as liberals have long wanted: effectively a national health care program for low-income people the way Medicare works for the elderly.

But you’re not likely to hear President Obama crow about this. He and his administration want to cast the health insurance law as a boon to the middle class and emphasize the expansion of the private health care insurance market to young adults and other politically-popular constituencies, not a program that benefits low-income people like food stamps. Republicans opposed ACA in part because they did not want to see Medicaid expanded, and their worst fears are being realized.

3. The website failures are fundamentally and negatively impacting Americans’ experiences with the law

I spent Monday at Southside Medical Center in downtown Atlanta, a community health care clinic where nearly all of the employees and patients are black, and many openly praise Obama. The patients, most of whom are uninsured, constantly ask center officials about signing up for “Obamacare,” a term they use with affection about a law they have heard about through the media and are eager to benefit from.

The center’s employees told me how most of the days over the last month have been disappointing, as they constantly have to tell patients to come back another time to try to enroll, because HealthCare.gov is down. A computer lab at the center, designed for patients to use to enroll in the new health care system after getting treatment, was empty on Monday, as the clinic employees didn’t feel confident enough that the website would work to send any patients there.

The current challenges with HealthCare.gov are not just a media obsession, as Obama’s aides often cast them. I’ve talked to strong Obama supporters with pre-existing conditions who are desperate to get health insurance and simply can’t get through the website process. The officials at Southside want to be able to log on to HealthCare.gov and scan through the health insurance options online directly with their patients, many of whom don’t have computers at home and are not very familiar with the health care system. They can’t do that right now, as the site nearly always locks them out at some point before they can finish the enrollment process.

And this not just a problem of HealthCare.gov, as some states, like Oregon, also don’t have well-performing health care sites.

A few weeks ago, President Obama and his aides were describing a process in which Americans could, from their computers, shop through a variety of plans and options, compare costs and then enroll online in less than a hour. Now, for Americans across the country, the process is much more cumbersome: fill out a paper application that asks for their income and family size, mail it to Department of Health and Human Services, wait 1-2 weeks for the government to respond with a package detailing the various health care options in their area, mail the form back with their choices, and then wait for a formal confirmation they are enrolled.

A process that was supposed to take a day will now take a month.

4. We don’t know if the website problems are deterring people from buying insurance

I’ve met people in my trips to Georgia and Kentucky who have no qualms with the website or the long process. They need insurance badly and either visit HealthCare.gov until they get through or fill out a paper form. These are people who are elderly or have some kind of condition that previously limited their ability to purchase insurance.

But the administration has a set of goal of having 2.7 million of the 7 million enrollees in the exchanges be between the ages of 18 and 35. If almost that many of the new enrollees are generally young, healthy customers, administration officials say, insurance companies will keep rates affordable for everyone who wants to purchase care, avoiding a situation in which high rates either force individuals to pay extremely high costs or the government to spend billions more than it expected on subsidies.

There has been much media speculation that young and healthy people will simply forgo insurance if HealthCare.gov remains slow and ineffective.

Obama administration officials argue this analysis is flawed, citing data from Massachusetts, which enacted a health care reform in 2007 that served as the model for the Affordable Care Act. In Massachusetts, enrollment in the health insurance plans spiked in December 2007, the deadline by which people had to buy insurance or face a fine. The administration argues that the equivalent of December 2007 in Massachusetts is March 2014 for the Affordable Care Act. Americans must purchase insurance by March 31 or face a fine of either 1 percent of their income or $95, whichever amount is larger.

“The fact that people aren’t signed up now is not at all interesting or important,” said Jonathan Gruber,the Massachusetts Institute of Technology professor who helped design both the Massachusetts law and the Affordable Care Act. “The success of health care reform has to be measured in months and years, not days and weeks.”

Right now, there is simply not enough data to know if people between ages 18 and 35 are unsuccessfully trying to buy insurance, turned off by the struggling website or simply not engaged in this process yet.

5. The South is a mystery

The states whose residents have the highest rates of obesity and lowest rates of having health insurance are mostly in the South. About 6 million uninsured people live in Texas and another 4 million in Florida, meaning that in those two states alone reside about 20 percent of the Americans without health insurance. And many of the states there are dominated by one or two health insurance companies, potentially leaving residents vulnerable to higher costs than in other states where several insurers are competing for Affordable Care Act customers.

But if little data exists throughout the country on the health care law, the South is even more opaque. Nearly all of the states in the region except for Kentucky and Arkansas, both of which have Democratic governors, have refused even token participation in the health care law. In this region, residents are wholly reliant on federal officials and HealthCare.gov. The South is one of the law’s biggest tests, but it’s too early to tell how it is performing on this region.