Take three

THE future of the Affordable Care Act—the ambitious, sprawling law better known as Obamacare—depends in part on modest places like Horizon Health Centre, in Jersey City. Its small lobby, with fluorescent lights and linoleum floor, boasts a framed thank-you note from the president. Horizon is, first, a clinic. It mostly treats black patients, Hispanics and immigrants from the Middle East. For the past two years, however, Horizon has also helped them get insurance. Staff have extolled Obamacare at churches and mosques, at meetings for students and meetings for prisoners. Now they are at it again.

It is sign-up season for Obamacare. On November 1st the law’s online exchanges opened for business, selling policies that begin in January. This year’s “open enrolment”, in certain respects, shows the law’s progress. In 2013 Obamacare’s computer programs sputtered. Horizon’s Nastassia Fleischer had to help clients sign up by phone. “This year the website is working great,” she says. More important, after years of touting Obamacare’s theoretical benefits, Democrats can now point to some real ones. In the past two years 17.6m have gained insurance. As with so much about the health law, however, Obamacare’s record remains devilishly complex.

That is inevitable, given the law’s tangled design. Obamacare bars insurers from raising costs for the ill. To broaden insurers’ pool of risk, the law fines those who do not buy coverage. It offers states money to extend eligibility for Medicaid, the health program for the poor. For Americans who are marginally better off, Obamacare gives subsidies to buy insurance on new online exchanges. Together, these provisions have had impressive results. The share of Americans without insurance dropped from 20.3% in October 2013 to 12.6% in September.

Even so, there are still more than 32m uninsured in America. Nearly twice as many people lack coverage as have gained it. Many will remain uninsured, for two reasons. First, millions do not qualify for subsidised coverage. More than 4m are undocumented immigrants, according to the Kaiser Family Foundation. Nearly 3m are uninsured because they live in states that did not expand Medicaid—perversely, they are also too poor to receive subsidies, which were intended for those earning $11,800 to $47,000 a year. A disproportionate number of these, nearly 1m, are black adults. Officials project only a modest increase of fewer than 1m new enrollees in 2016. Second, many who do qualify for Medicaid or for subsidies will not sign up. Some states, wary of costs, make it difficult to enroll in Medicaid. Most of the uninsured do not know they might qualify for subsidies. And many will have sticker-shock when they see the cost of premiums.

In Obamacare’s first two years, insurers set prices before knowing their costs. Only about 35% made money in 2014, according to McKinsey, a consultancy. This year more health plans left the market than entered it. Insurers are adjusting their prices. Some are lower; many are higher. In Indiana, for instance, the average premium of a standard plan for a 27-year-old is 12% lower than it was last year. In Oklahoma, the average price jumped by 36%.

On November 3rd Kentucky voters elected a new Republican governor, Matt Bevin, who ran on a pledge to dismantle a law that has helped half a million residents of his state gain coverage. With Obamacare, politics is never far away.