How Will We Know If Obamacare Is a Success?

| Fri Apr. 18, 2014 11:26 AM EDT

Will Obamacare be a success? Ross Douthat thinks we should all lay down some firm guidelines and hold ourselves to them. Here are his:

For my own part, I’ll lay down this marker for the future: If, in 2023, the uninsured rate is where the C.B.O. currently projects or lower, health inflation’s five-year average is running below the post-World War II norm, and the trend in the age-adjusted mortality rate shows a positive alteration starting right about now, I will write a post (or send out a Singularity-wide transmission, maybe) entitled “I Was Wrong About Obamacare” — or, if he prefers, just “Ezra Klein Was Right.”

Let's take these one by one. I'd say a reduction in the uninsured of 25 million is a pretty good metric. If, by 2023, the number is substantially below that, it would be a big hit to the law's success. Getting people covered, after all, has always been the law's primary goal. What's more, I'd be surprised if more states don't expand Medicaid and get more aggressive about setting up their own exchanges by 2023. At some point, after all, Republican hysteria about Obamacare just has to burn out. (Doesn't it?)

On health inflation, I think running below the post-WWII average is a pretty aggressive standard. That would require health care inflation of about 1 percent above overall inflation. If we manage to keep it to around 2 percent, I'd call that a reasonable result.

But my biggest issue is with the age-adjusted mortality rate. I know this is a widely popular metric to point to on both left and right, but I think it's a terrible one. Obamacare exclusively affects those under 65, and mortality just isn't that high in this age group. Reduced mortality is a tiny signal buried in a huge amount of noise, and I very much doubt that we'll see any kind of clear inflection point over the next few years.

So what to replace it with? I'm less sure about that. Maybe the TIE guys would like to weigh in. But this is a longtime hobbyhorse of mine. Medical care does people a ton of good even if it doesn't save their lives. Being able to afford your asthma inhaler, or getting a hip replacement, or finding an antidepressant that works—these all make a huge difference in people's lives. And that's not even accounting for reduced financial strain (and bankruptcies) and lower stress levels that come from the mere knowledge that a doctor is available if you need one—even if you don't have a life-threatening emergency that requires a trip to the ER.

In addition, I'd probably add a few things. Douthat doesn't include any negative metrics, but critics have put forward a whole bunch of disaster scenarios they think Obamacare will be responsible for. It will get harder to see doctors. Pharmaceutical companies will stop innovating. Insurance companies will drop out of the exchanges. Premiums will skyrocket. Etc. Without diving into the weeds on all these possible apocalypses, they count as predictions. If, in 2023, we all have to wait months for a routine appointment, or we can't get the meds we need because drug companies have gone out of business, then Obamacare is a failure regardless of what else it does. I don't think these things will happen, but they're surely on my list of metrics for judging the law's success.

UPDATE: Whoops. It turns out that one of the TIE guys, Austin Frakt, has already weighed in on this. You can read his comments here.