If you are a law­ful res­i­dent of the Unit­ed States and you lack health insur­ance today, it’s almost cer­tain­ly your fault.  You can’t blame your employ­er, the gov­ern­ment or the insur­ance com­pa­nies.  It’s on you.

That is the last­ing achieve­ment of Oba­macare, whose sec­ond open enroll­ment peri­od began yes­ter­day. Gone are the days when peo­ple with pre-exist­ing med­ical con­di­tions could not find afford­able cov­er­age.   Whether the ends of this achieve­ment, which are unde­ni­ably good, jus­ti­fy the means its sup­port­ers employed to win its enact­ment remains a mat­ter of controversy.

One of the law’s prin­ci­pal archi­tects, MIT’s Jonathan Gru­ber, has defend­ed those means, say­ing that the “stu­pid­i­ty of the Amer­i­can peo­ple” neces­si­tat­ed the President’s “lack of trans­paren­cy” about the law’s pro­vi­sions.  The unwashed mass­es, in Gruber’s view, sim­ply lacked the capac­i­ty to grasp how good the law was for them, so their rulers had to mis­lead them about its hid­den tax­es, cross-sub­si­dies and the series of unpleas­ant sur­pris­es that would befall every step of its implementation.

Gruber’s view, no doubt qui­et­ly shared by the com­mu­ni­ty of health pol­i­cy experts who pro­duced this law, gives Amer­i­cans too lit­tle cred­it and its authors too much.  The Pres­i­dent sure­ly knew that mil­lions would lose the cov­er­age they liked and lied about it in order to get the law adopt­ed and imple­ment­ed.  He sure­ly did not know that deba­cle would accom­pa­ny the launch of the health insur­ance exchanges, that his Admin­is­tra­tion would have to waive numer­ous pro­vi­sions of the law and ignore oth­ers because they were so shod­di­ly writ­ten, that it would have to delay the employ­er man­date, that it would have to defy the law in order to allow Con­gres­sion­al employ­ees to keep their gov­ern­ment sub­si­dies, that the Supreme Court would strike down the law’s require­ment that states expand their Med­ic­aid pro­grams as well as a pro­vi­sion that vio­lat­ed the First Amend­ment, or that, five years after its enact­ment, that same court would be hear­ing oral argu­ments on whether one of its core pro­vi­sions – health insur­ance pre­mi­um sub­si­dies for peo­ple who enroll through the fed­er­al exchanges – is also unlawful.

The Administration’s ser­i­al blun­ders on Oba­macare make Gruber’s charge of stu­pid­i­ty look, shall we say, misdirected.

Blun­ders aside, here’s what we know – and still don’t know – about the most con­se­quen­tial law in a generation.

What We Know

1. Few­er peo­ple are unin­sured. How many few­er isn’t yet clear.  CDC esti­mates that the ranks of the unin­sured have been trimmed by near­ly 4 mil­lion (to 41 mil­lion from 44.8 mil­lion).   The more author­i­ta­tive sur­vey by the Cen­sus Bureau sug­gests that the num­ber of unin­sured bare­ly budged (from 45.6 mil­lion in last year’s sur­vey to 45.2 mil­lion in the one con­duct­ed this past March), although that sur­vey arguably failed to cap­ture part of the surge in enroll­ments that occurred dur­ing March and April.   HHS, evi­dent­ly embar­rassed by the Administration’s offi­cial num­bers, ignored them in a recent report, instead cit­ing a more favor­able study based on Gallup poll results.  Shop­ping around for num­bers miss­es the larg­er point: more peo­ple have cov­er­age today than if the law had not been passed and even more will gain cov­er­age in com­ing years.  That is a good thing, what­ev­er the num­ber turns out to be.
2. Exchanges remain a mess. Here’s the media nar­ra­tive on exchanges: they were a dis­as­ter for three or four months, but they turned the cor­ner and start­ed to work well.  Not quite.  It’s true that the fed­er­al gov­ern­ment and that of sev­er­al states (includ­ing Mass­a­chu­setts, on which Oba­macare alleged­ly was mod­eled) botched the rel­a­tive­ly easy task of let­ting peo­ple shop online for cov­er­age.  Online shop­ping is hard­ly cut­ting edge.  Ehealth­in­sur­ance has been doing it for years. Sure­ly the gov­ern­ment couldn’t screw that up.  Turns out that it could, and for sev­er­al months did, although that part of the exchanges is expect­ed to work rea­son­ably well this time around.   The prob­lem is that exchanges are sup­posed to do more than just let peo­ple select a plan.  They’re required to deter­mine eli­gi­bil­i­ty for sub­si­dies, ver­i­fy house­hold income and whether the appli­cant is a law­ful U.S. res­i­dent, make sure that sub­sidy checks go to the insur­ance com­pa­ny in the right amount on a month­ly basis and per­form oth­er such admin­is­tra­tive func­tions.  This so-called “back end” of the exchanges still doesn’t work the way it’s sup­posed to and prob­a­bly won’t any­time soon.
3. The insur­ance prod­uct is awful. If you were to pick the two fea­tures of insur­ance poli­cies that peo­ple hate most, they would be restric­tive net­works (e.g., HMOs) and high deductibles.  Oba­macare com­bines both these fea­tures into most of the prod­ucts sold through the exchanges.  That could prove a con­tin­u­ing irri­tant to consumers.
4. Pre­mi­ums are afford­able. Rel­a­tive­ly low pre­mi­ums are the result of this bit­ter brew of tight net­works and high cost-shar­ing.  Peo­ple may not be crazy about the prod­uct, but fears of “rate shock” gen­er­al­ly haven’t mate­ri­al­ized.  That said, the plans with the largest enroll­ment are the ones that have raised their 2015 pre­mi­ums the most, so many con­sumers will have to change insur­ers to avoid or min­i­mize rate hikes. Those who don’t switch will auto­mat­i­cal­ly be re-enrolled in their exist­ing plans. That will pro­duce some unhap­py results, par­tic­u­lar­ly for those now receiv­ing subsidies.
5. Worst. Law. Ever. I was involved in draft­ing health care leg­is­la­tion for many years.  Some of the things that I had a hand in writ­ing (Medicare Part D and health sav­ings accounts) actu­al­ly became law.  It is a com­pli­cat­ed busi­ness and I cer­tain­ly have made mis­takes.  But if any­thing I’d helped write had been this slip­shod, ama­teur­ish and unwork­able, I prob­a­bly wouldn’t be chirp­ing at eco­nom­ic sem­i­nars about the “stu­pid­i­ty of the Amer­i­can people.”

What We Still Don’t Know

1. Is demand for health insur­ance less than had been assumed? When Oba­macare was enact­ed, CBO esti­mat­ed that it would reduce the num­ber of unin­sured to 21 mil­lion in 2016;  now they believe that 30 mil­lion will remain unin­sured in that year.  That’s a big dif­fer­ence and one that has com­pli­cat­ed caus­es, but it does sug­gest that there may not be a huge pent-up demand for health insur­ance. Reduc­ing the num­ber of unin­sured even to 30 mil­lion over the next two years will require a big uptick in exchange enroll­ments.  CBO projects that exchange enroll­ments will near­ly dou­ble next year to 13 mil­lion and near­ly dou­ble again in 2016 to 24 mil­lion.   HHS now believes that the num­ber of enrollees next year will be far less, esti­mat­ing that 9–10 mil­lion peo­ple will sign up dur­ing this open sea­son. If this esti­mate proves accu­rate, we may end up with more than 30 mil­lion unin­sured on a long-term basis, bar­ring oth­er changes (like grant­i­ng legal sta­tus to peo­ple not law­ful­ly present in the U.S.).
2. Will more peo­ple agree to pay full price for their health insur­ance? Speak­ing of demand for health insur­ance, it appears that peo­ple don’t want it if they have to pay the full price.  Three out of four peo­ple who com­plet­ed appli­ca­tions dur­ing the first open sea­son and who were told that they did not qual­i­fy for a sub­sidy didn’t both­er to select a plan.  Only 15 per­cent of those who enrolled dur­ing the first open sea­son are pay­ing an unsub­si­dized pre­mi­um.  This isn’t ter­ri­bly sur­pris­ing.  The aver­age month­ly sub­sidy for peo­ple enrolled through the exchanges was $264, or about 76 per­cent of the aver­age month­ly pre­mi­um.  That’s pret­ty sim­i­lar to the sub­si­dies received by those who get cov­er­age from oth­er sources.  Employ­er con­tri­bu­tions to health pre­mi­ums aver­age around 72 per­cent, which is what the fed­er­al gov­ern­ment con­tributes, on aver­age, to the pre­mi­ums of its employ­ees. Pay­ing — or, more accu­rate­ly, think­ing that you’re pay­ing — only a por­tion of the pre­mi­um is a time-hon­ored Amer­i­can cus­tom.  Oba­macare has not yet con­vinced peo­ple that pay­ing an unsub­si­dized pre­mi­um is a good deal.
3. Can Oba­macare sur­vive with­out cor­po­rate wel­fare pay­ments to insur­ers? Every­body knows about income-based sub­si­dies to needy indi­vid­u­als.  Few have paid much atten­tion to gov­ern­ment sub­si­dies to needy insur­ance com­pa­nies.   This cozy lit­tle arrange­ment includes a $10 bil­lion “rein­sur­ance” pay­ment that the gov­ern­ment is mak­ing to such plans this year.  On aver­age, tax­pay­ers give insur­ance com­pa­nies $1,408 for each of the 7.1 mil­lion peo­ple enrolled through the exchanges, or about $117 per enrollee per month.  With­out this cor­po­rate wel­fare, the aver­age month­ly pre­mi­um for plans sold through the exchange would be $463 instead of $346.  But there’s more.  The gov­ern­ment also is promis­ing to pay these same insur­ers bil­lions more through some­thing called “risk cor­ri­dors.”  Both the Gen­er­al Account­abil­i­ty Office and the Con­gres­sion­al Research Ser­vice have said that it is unlaw­ful for the gov­ern­ment to make these pay­ments absent an appro­pri­a­tion.  The Admin­is­tra­tion will make them any­way.  And my guess is that the gov­ern­ment will con­tin­ue to make them long after these sup­pos­ed­ly tem­po­rary pro­vi­sions are set to expire.  The Pres­i­dent pro­fess­es to hate insur­ance com­pa­nies, but he just might have a secret crush on them.
4. How will vot­ers react next year when the tax on the unin­sured is col­lect­ed for the first time? There’s a new tax in town and peo­ple will find out about it when they fill out their 1040s ear­ly next year.  If you lacked health insur­ance cov­er­age for any month dur­ing 2014, you have to pay the new tax, unless you qual­i­fy for a “hard­ship exemp­tion.”  The tax will be deduct­ed from your refund check.  The pub­lic might just take this in its stride.  On the oth­er hand, it might stir anoth­er round of resent­ment over the law.
5. Will the Supreme Court rule against Oba­macare? Hard to believe, but this March the court will mark the fifth anniver­sary of the law’s enact­ment by hear­ing oral argu­ments in a chal­lenge to the law’s sub­si­dies.  Their deci­sion in the case is expect­ed next June.  The law says that sub­si­dies are avail­able only for pre­mi­ums pur­chased through a state exchange.  Some 36 states do not oper­ate such exchanges, hav­ing turned that task over to the fed­er­al gov­ern­ment.  In a relat­ed case, a three-judge pan­el from the D.C. Cir­cuit Court of Appeals ruled that it is unlaw­ful to pay sub­si­dies on behalf of peo­ple enrolled in such fed­er­al exchanges.  In essence, the Court must decide whether the law is what Con­gress, bless their point­ed lit­tle heads, meant to write or what they actu­al­ly wrote.  If the Supreme Court upholds the let­ter of the law and strikes down the sub­si­dies, then Con­gress would almost cer­tain­ly have to rewrite the law.

Which, come to think of it, might not be such a bad idea.