As the 7.1 million sign-ups prove, ObamaCare has pulled out of the station without a train wreck, yet multiple engineering flaws — gaps and cut-corners — are already being exposed by consumer experiences.
Many passengers are grateful for the law's large subsidies, especially those with low incomes and conditions that had made it impossible to afford coverage.
But for many passengers in other cars on the train, the first few months have been jarring, and that should be a big warning sign at this early stage. The stresses now becoming obvious are likely to grow more severe, both because the nature of the law that gradually shifts the burden of premiums to the insured and the political backdrop that makes ObamaCare so hard to repair.
Those stress points include: 1) Deductibles that can be sky-high for low-income households.
2) Ultranarrow provider networks making it hard for some to get care while socking others with unexpectedly large bills.
3) A family penalty that denies subsidies to modest-income households when one spouse is offered employer coverage.
4) A subsidy cliff that can leave older workers of moderate means paying an excessive share of income for coverage.
5) Tax penalties that employers have sought to avoid by cutting low-wage worker schedules below 30 hours per week.
6) A Medicaid gap opened by a Supreme Court decision that has left millions below the poverty line — including those who have lost work hours — with no help in states that have opted against the expansion.
The Bronze Trap
Alfred Chavis, 56, got a bronze policy for just $1 per month. But the Philadelphia maintenance worker, whose part-time job puts him not too far above the poverty level, faces an eye-popping deductible of $6,350, he told the Wall Street Journal.
Some advocates have warned of low-income households falling into the law's bronze trap: Because they may be unwilling or unable to pay 2% to 6% of income for an ObamaCare exchange silver plan, they could wind up paying one-third of their income in medical bills before benefits kick in.
Credit-rating agency Moody's warned recently of a "significant risk that people covered by the most popular insurance plans will be unable or unwilling to meet their deductibles.
Dwight Showley, married with two children, signed up for a Covered California exchange plan in January. Since then, he learned that his family's pediatrician will no longer accept his Blue Cross coverage, nor will the family doctor or OB-GYN. Initially, he had signed up for an off-exchange plan (after his pre-ObamaCare plan was canceled), but switched to an exchange plan after his newborn's first doctor's visit was out of network.
Now he's decided that the family will go without insurance, he told the Visalia Times Delta.
Seattle Children's Hospital told Politico that in January it received referrals for 300 kids whose families were faced with decisions about whether to keep their coverage or pay for expensive out-of-network coverage.
Though it is the only children's hospital in Washington state, it is out of network for half the exchange plans.
Phoenix Children's Hospital told the Arizona Republic that some insurers were "taking a hard line" in refusing to pay anything for the out-of-network treatment to patients on ObamaCare plans referred with cancer and heart ailments.
Some physicians and hospitals say the shift to narrow networks has gone beyond rewarding efficiency to winnowing out quality and making their services uneconomical. The Obama administration seems to agree there's a problem and is mulling new minimum network standards that insurers warn will drive up premiums.
The Columbia Journalism Review has followed the saga of an Illinois family shut out of subsidies because the husband has employer coverage. The wife and five children will remain uninsured because they can't afford premiums that would cost 13% of family income.
The University of California Berkeley Center for Labor Research says 2 million or 3 million adults and children may be subject to this family penalty.
Anne Cornwell, 59, of Gaston County, N.C., also will go without insurance because she and her husband are just on the wrong side of the subsidy cliff, making $72,000 a year.
With no subsidies available, they'd have to spend about 15% of income on premiums for the cheapest high-deductible bronze plan, she told the Lake Wylie Pilot. Her husband is unemployed, making ObamaCare's age-rated costs too much of a stretch Shorter Shifts
Walter Shepherd told MSNBC of his daughter who works at a North Carolina Hardee's where she's limited to 26 hours per week. Employers can minimize ObamaCare costs by limiting workers to less than 30 hours a week. ObamaCare's employer insurance mandate for full-timers helped drive workweek in low-wage private industries to a record low 27.45 hours in November, before the bad weather hit.
Her income is too high to qualify for Medicaid but below the poverty line at which eligibility for exchange subsidies begins.
ObamaCare commits the federal government to completely fund the Medicaid expansion through 2016 and 90% after that. Still, a majority of GOP-led states have rejected the funds, a testament to just how deep opposition to ObamaCare runs.
Each year, if premiums outpace income growth, as is typical, a bigger share of costs will shift to individuals and families. While the individual mandate tax penalty will ramp up for those who go uninsured, it's unclear whether the Obama administration and Congress are prepared to apply this stick if discontent with ObamaCare's high deductibles and narrow networks remains high.