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1. CDCThe decision to study public health does not mean you must go through traditional courses at a university. The Centers for Disease Control and Prevention, or CDC, offers free online public health courses in environmental public health. The 15 courses provided by the CDC allow students to learn a variety of topics that range from environmental factors that may impact public health to food safety at the professional and personal level.A key way the CDC stands apart is the focus on the organization. The CDC is not an educational institution like a college or university. The primary goal of the CDC is to address public safety concerns. Due to the focus of the government organization, online courses focus on areas that may impact the lives of individuals in different environments and localities. It strives to provide information to anyone with an interest in public health rather than students who are looking for credit in a college or university. The CDC offers courses through an on-demand system that allows students and professionals to work around their schedules and obligations.Courses: Environmental Public Health Online Courses– 15 related courses2. DOANE UNIVERSITY/EDXDoane University offers a free online course in public health with a focus on health informatics technology. It strives to provide intermediate knowledge that helps students who plan to work in informatics or the healthcare industry. It focuses on population data or large groups rather than individual care as it applies to informatics and healthcare technology.A key way Doane University’s program stands apart is the short amount of time required for the program. Students can complete the course in three weeks if they set aside an appropriate amount of time. It is not a long course, so it allows students to finish the work when it fits their situation and schedule. The amount of time required for the course on a week-to-week basis is around five to ten hours per week. Students will want to evaluate their schedule to ensure they have time for the degree; however, it is a flexible program that allows students to work at their own pace. The online public health course from Doane University allows students to obtain a certificate with a small fee.Courses: Health Informatics Technology in Population Healthcare Analytics3. DUKE UNIVERSITY/COURSERADuke University offers a free online public health course with a focus on global health. The Challenges of Global Health course focuses on identifying the problems that impact populations on a global scale. It also strives to identify the cause of health concerns and focuses on solutions that may assist in preventing problems in the future. The course focuses on the global perspective and populations as a whole rather than small groups within a population for a wide view of public health.A key way Duke University stands apart is the flexibility of the course. Students can adjust their deadlines to fit a personal schedule and have the ability to work on the course through the online system. It does not require students to attend classes on-campus. The fully online program also allows students to work on their course work or listen to lectures at any location with an Internet connection. The beginner level course from Duke University only requires 10 to 11 hours of time to complete the lectures and assessments.Courses: The Challenges of Global Health4. GLOBAL HEALTH LEARNING CENTERThe Global Health Learning Center offers free online public health courses to help students reach their goals for their studies. The public health courses range from cancer prevention to antimicrobial resistance and family planning. Students have many courses to choose from without a high cost for their education. The opportunity to study a variety of topics ensures that students have access to studies that may assist with their specific goals for a career or continuing education.The Global Health Learning Center stands apart by offering certification programs as well as individual courses in public health topics. The certifications may help students who want to obtain a career in public health or related fields by giving them a clear understanding of important topics that may impact their career plans. It also gives students access to many fields of study as it relates to public health and safety. The Global Health Learning Center offers USAID continuous learning credits for some of the online courses.Courses: Global Health Learning Center5. HARVARD UNIVERSITY/EDXHarvard University offers two free online public health courses for students who want to build on their knowledge or start gaining an understanding of a specific topic. The intermediate course focuses on global health as it applies to quality and safety. The beginner course focuses on the effects of climate change on human health and populations. Students can take the courses for free and focus on accomplishing their goals for a career.The way Harvard University stands apart from other programs is the accelerated focus of the courses. Students can finish the courses in seven or eight weeks, which allows them to work at a fast pace. It also offers a flexible online schedule that allows students to work around their personal schedule and obligations when studying for continuing education or to learn valuable details that may help in their career. Students can obtain a certificate after finishing the online courses from Harvard University by paying a small fee.Courses: Improving Global Health: Focusing on Quality and Safety; The Health Effects of Climate Change6. INSTITUTE FOR HEALTHCARE IMPROVEMENTThe Institute for Healthcare Improvement offers an online course in quality and safety as it relates to populations. The courses focus on introductory topics that help students learn the basics they need to understand before moving into more advanced studies. The intermediate courses focus on specialized topics of discussion as it relates to healthcare and populations.The Institute for Healthcare Improvement stands out for offering translations of course material in French, Spanish, and Portuguese. Students can take courses in the language that is most comfortable for their studies. It gives students who may not be fluent in English an opportunity to complete the course and learn the same lessons. The Institute for Healthcare Improvement breaks down lessons into 15 to 40 minute long sessions to make it easy for students to keep up with the course material.Courses: Triple Aim for Populations7. JOHNS HOPKINS UNIVERSITY/APPLE ITUNESJohns Hopkins University offers a free public health course with a focus on the history of the field of study. The free course focuses on the historical context of public health as an industry and how it has changed over time to reflect improvements in knowledge, medical science, and new theories. It also discusses historical ailments and sicknesses and the ways the concerns were resolved.Johns Hopkins University stands apart by offering a comprehensive look into the development and growth of public health measures that improve public safety in modern life. It strives to ensure that students have a clear understanding of the changes that have occurred over time as well as the way current public health issues may relate directly to historical context and situations. It gives students a strong foundation that helps them understand important topics of discussion in public health and safety. The Johns Hopkins University course on public health history is available for free through the Apple iTunes store for students to download onto a smartphone or tablet.Courses: The History of Public Health8. JOHNS HOPKINS UNIVERSITY/COURSERAJohns Hopkins University offers two free courses in public health through Coursera’s online system. The course on biostatistics in public health is a beginner level course that explores statistical data and analytical methods used in public health for improved skills when it comes to reading biomedical research statistics and related data points. The Foundations of Global Health course is also a beginner level course that offers a strong foundation when it comes to public health as it applies to a global environment.A key way Johns Hopkins University’s courses at Coursera stand apart is the flexible format. Students can study when it fits their schedule and have access to course materials at any location with a computer, laptop, or tablet. The course is fully online and students do not need to attend any classes at the college to complete the course. The courses from Johns Hopkins University require 10 weeks or less to complete based on student preferences and personal scheduling.Courses: Biostatistics in Public Health; Foundations of Global Health9. JOHNS HOPKINS UNIVERSITY/JHUSPH OPENStudents who want to study a variety of topics related to public health from Johns Hopkins University can focus on the free courses available at JHSPH Open. Students have access to many courses that range from animals in research and foodborne bioterrorism to global tobacco control and child development. You have access to many online free courses that allow you to focus on an area of study that fits your long-term goals for your career and interests.The courses from Johns Hopkins University at JHSPH Open stand apart by providing a well-rounded view of public health. The array of courses allows students to recognize the different ways public health impacts local and global environments. It also strives to give students a strong foundation in the risks to public health and safety that may arise in modern environments. Students can separate courses at Johns Hopkins University by topic or by collection to make it easier to follow through with a topic as it applies to public health.Courses: JHUSPH Open10. KAROLINSKA INSTITUTET/EDXThe Karolinska Institutet offers a free course in the introduction to global health online that allows students to learn the foundation they need to build on their skills and knowledge. The course focuses on variations in health outcomes based on different countries and localities. It also explores differences based on gender and uses a perspective of equality to help shed light on important topics in public health.A key way the Karolinska Institutet stands apart from other options is the accelerated pace. The course requires only six weeks of time to complete and students can work on the classes when it fits their personal schedule. It offers an online format that makes it easy for students to keep up with the course from any location. The course from the Karolinska Institutet does not require any prerequisite courses and is designed for beginners to the study of public health.Courses: An Introduction to Global Health11. LIBERTY UNIVERSITY/APPLE ITUNESLiberty University offers a Community Health Nursing course for free through the Apple iTunes store. The free course focuses on the role of nurses in community health as well as the impact of environmental factors on a local community. It strives to ensure that nurses understand how to adapt to different situations that may arise when working with a community.Liberty University stands apart by offering a free course without any prerequisite standards. Students in nursing, public health, or any other field of study can take the course through the iTunes store. That allows students to gain a broad understanding of public health as it relates to nursing and local communities. It is a flexible solution for students who may have limitations on their time. The course from Liberty University takes a Biblical approach to the public health and nursing topics discussed in the course.Courses: Community Health Nursing12. MIT/EDXThe Massachusetts Institute of Technology, or MIT, offers a free online public health course on global health informatics with a focus on improving quality of care in a medical setting. The course work is advanced, so it is ideal for students to have previous knowledge when it comes to informatics and medical technology. It is not designed for students who are starting out in their degree and do not have the fundamental knowledge about public health and informatics to help with their understanding of the course material.MIT stands apart from other courses by focusing on the computer science aspects of public health and medicine. It recognizes the role of technology in modern medicine and provides students with a clear idea of how technology may change the quality of care given to patients. Improvements to medical technology may impact long-term public health strategies and MIT prepares students for the challenges that may arise over time. MIT’s online course allows students to obtain a certificate for a small fee that may help when it comes to employment opportunities or proving knowledge of informatics.Courses: Global Health Informatics to Improve Quality of Care13. NATIONAL CENTER FOR DISASTER PREPAREDNESS/COLUMBIA UNIVERSITYThe National Center for Disaster Preparedness through Columbia University offers an online course in public health that helps students with their long-term goals. The course in surveillance and forecasting of emerging diseases teaches students how to resolve problems in emergency situations that may arise when an infectious disease develops. It strives to prepare students for different scenarios so that they can react quickly.The National Center for Disaster Preparedness stands apart by focusing on the possibility of predicting or identifying diseases before it causes an epidemic. By focusing on the possibility of forecasting an infectious disease as it starts to emerge into a population, public health professionals can take measures to limit the risks to the population. Students take a pre-test and a post-test for the course before receiving a certificate.Courses: Surveillance and Forecasting of Emerging Infectious Diseases14. NEXTGENUWhen you are looking for free online public health courses to improve your understanding of a topic or for personal interests, NextGenU offers several options for your goals. NextGenU has long been recognized for their free online public health courses, but they have recently made an even bigger step – offering the first entirely FREE online MPH degree. Developed in partnership with the WHO, the CDC, and many other organizations, NextGenU has upped the ante for free public health education.A key way NextGenU stands apart is the dedication to free education. Not only do they offer multiple online courses for free that allow students to get credits for their degree. They have built those courses and their degree on the highest level of expertise and reach, giving their students access to the very best minds in public health. NextGenU is the first organization to offer a free online degree for students who plan to study public health.Courses: NextGenU Courses15. OPENSUNY/COURSERAOpenSUNY offers free online public health courses that help you focus on valuable skills for your career. The free course available through the school is Global Health Diplomacy. The course focuses on teaching students about the different ways politics, finances, and diplomacy interact to make decisions on a global scale in relation to health and public safety. The degree goes beyond the medical topics and terminology to help students recognize other factors that may impact public health on a global scale.A key way OpenSUNY stands apart is the flexibility of the free online course. The beginner level course in public health allows students to sign up for the class at different times throughout the year. It is a fully online program, which allows working adults to complete the class when it fits their schedule. It also allows many students to sign up for the free course, so many students can take the class. OpenSUNY offers accelerated online courses, and the free course in public health is a seven-week class that students can complete when they have time.Courses: Global Health Diplomacy16. PENN STATE/COURSERAPenn State offers a free online course in Epidemics with a focus on the Dynamics of Infectious Diseases. The online course recognizes that infectious diseases are a complex problem that impacts public health and safety. It offers insights into the history of disease control and methods of preventing sicknesses, as well as the complications associated with infectious diseases that may cause harm to human health or death in a modern medical environment. It helps students understand the potential concerns that may arise as bacteria and viruses evolve and complicate medical treatments.The way Penn State’s free online course stands apart is the direct focus on infectious disease and the spread of sicknesses. The program explores different infectious diseases that have caused epidemics and death in the past, as well as the risks associated with disease adaptation to medical treatments. It allows students to gain a firm understanding of a basic topic of discussion for public health. The program takes around 16 hours to complete and offers flexible deadlines to allow students to work on their studies when they have the time.Courses: Epidemics – the Dynamics of Infectious Diseases17. SDG ACADEMY/EDXSDG Academy offers a free online public health course in Global Public Health that allows students to understand the role of institutions and infrastructure within local communities and areas on global public health. It explores the impact of healthy individuals on their surroundings and interactions and strives to identify the connections between economics, social interaction, and environment on health. The online course from SDG Academy allows students to obtain a verified certificate to show they completed the course, which may help with job opportunities or gaining credits for a degree.A key way SDG Academy stands apart for their free online course is the focus on environmental factors and human health. The program teaches students about the way community health influences economics, migration to new locations, and trade. It also touches on the impact of health on the food systems of a local environment and how changes to a food system may impact the health of local communities.Courses: Global Public Health18. STANFORD UNIVERSITY/COURSERAStanford University offers a free online course in International Women’s Health and Human Rights that allows students to gain a strong foundation in topics related to the rights of women around the world. The course focuses on the lives of women from infancy until they reach old age, and the way rights impact the health and well-being of women in different regions of the world.A key way Stanford University stands apart from other programs is the focus on flexibility. The course takes around 48 hours to complete, but the flexibility ensures that students are able to finish the course within eight weeks. You can also take more time to complete the course and finish it in 11 weeks if you have obligations that limit your time. That level of flexibility ensures that you are able to stay on track and finish your coursework when it fits your schedule. Students can purchase a certificate for the course in International Women’s Health and Human Rights from Stanford University if they want to gain credit or use the certificate for continued education in their job.Courses: International Women’s Health and Human Rights19. UC BERKELEY/OPEN ACADEMYThe University of California at Berkeley, or UC Berkeley, offers three online courses in public health for free. Students can study the control of infectious diseases, ethics as it applies to public health intervention or preparedness for public health emergencies. The classes offer students an opportunity to learn about useful topics in the public health field and develop skills that apply to their career goals.A key way UC Berkeley stands apart is the array of classes. The school offers three free online courses that help students with their goals in relation to public health. The courses range from 10 to 13 lectures, and students are able to work at their own pace to complete the class. It allows students to gain insights into important topics without worrying about the financial aspects of the degree. UC Berkeley stands apart by following a simple online format that allows working adults to complete the classes when it fits their situation. Students can start the lectures without wasting time on applications due to the simple video format.Courses: Ethical Challenges in Public Health Intervention; Public Health Preparedness and Emergency Response; Epidemiology and Control of Infectious Diseases20. UC IRVINE/APPLE ITUNESWhen you want to take free online public health courses, you can take the Foundations of Public Health from UC Irvine course. The free course is a fundamental course that is designed around the needs of students who want a firm grasp of public health topics. It is designed for graduate-level students who have some understanding of basic topics, but want to delve deeper into the fundamentals of public health research. Students can work on the course materials at their own pace.UC Irvine differs from other programs by offering their free course through Apple iTunes. The format available through iTunes makes it easy for students to access and take the classes. It is possible to use an Apple phone, tablet, or device to follow the materials. Students can also use their computer and iTunes account to access the materials. That allows students to listen to lectures or keep up with classwork in any location. UC Irvine requires students to get consent from an instructor or to have a graduate degree to take the free course.Courses: Foundations of Public Health

If the primary goal of the ACA is to move the population substantially towards universal coverage, the data shows that it is making significant progress towards that goal. It is no panacea for the diseases of the American health care system, but—judged by its own goals—it seems to represent a modest improvement on the status quo.However, there are worrying signs that its gains may not be sustainable. Important metrics in the individual insurance market are moving in the wrong directions, which may be a sign that some of the ACA’s core mechanisms are poorly calibrated and unstable. If they are, the individual insurance market may collapse—and fixing it will be politically difficult for the Democrats.Increasingly InsuredLeaving aside various mandates for specific benefits, like women’s contraception and preventative care, the primary goal of the ACA is to increase access to health insurance, and thereby increase access to health care for those who were previously uninsured. CDC data on health insurance has so far been rosy: More people have health insurance than ever before, and the subgroups specially targeted by the ACA are growing most of all.Medicaid ExpansionThe most straightforward part of the ACA to evaluate is the expansion of Medicaid, both by raising the income cap to 133% of the poverty line and by removing other state-specific conditions which tended to shut out those who were young, male, unmarried, or childless. This has been very successful: Far fewer poor people were uninsured in 2015 than in 2010.Moreover, this nearly twenty-point reduction in the ranks of the uninsured poor occurred without the 19 states which refused to implement the Medicaid expansion. Courtesy of their Republican legislatures, we have an interesting natural experiment: Did states which implemented the Medicaid expansion see different changes in insurance than states which didn’t? The answer is yes, they did: People who were insured by public programs in states with the Medicaid expansion have remained uninsured in states without the expansion.Medicaid isn’t the greatest insurance, of course, and there are some interesting studies suggesting that Medicaid may have more of an impact on your bank statements than your blood tests. But whatever Medicaid’s benefits may be, they are clearly now being provided to many more people than before.Young Adult CoverageThe ACA includes a provision requiring that insurance plans which cover children continue that coverage until age 26. Combined with the Medicaid expansion, this has dramatically reduced the number of adults 18–24 without insurance.This is important for members of this age group because they are usually either students or entry-level employees and would struggle to afford health insurance. But it’s important to the health care system as a whole because young adults are less likely to actually need to use their insurance.Health insurance works by having many healthy people pay for a few sick people. If there aren’t enough healthy people, each person will have to pay a higher premium. Young adults are a large group of healthy people, but they are not in a position to pay for themselves. By getting their parents to pay for them instead, however, they are included in the pool.(Yes, the ACA says that this coverage expansion is free. But like most laws requiring a company to provide something for “free”, the cost ultimately will be incorporated into something else.)The ‘Uninsurable’If allowed to choose their customers, insurers will virtually never choose to enroll somebody with a pre-existing condition which is expensive to treat. From their perspective, it’d be like betting on a horse that has been scratched from the race: There is zero chance that they will make money on that customer. You could still get insurance through an employer plan, but the individual market was essentially closed to you: Plans would either be very expensive, or completely unavailable.Under the ACA, this is no longer permitted: Insurers may not look at the specifics of a person’s health history when deciding whether to accept their application. Nor may they exclude pre-existing conditions from their coverage, or set a dollar limit on the amount of care they will provide. This is obviously a boon for anybody with expensive health issues.Unfortunately, I wasn’t able to find any pretty graphs or detailed numbers to illustrate this point, perhaps because the number of ‘uninsurable’ people appears to have been relatively small. At various times, state and federal governments ran “high-risk pools”, special insurance programs which were allowed to operate at a loss so they could provide insurance to the uninsurable. Enrollment in these programs, however, never rose above roughly 200,000 nationwide. Partly this was because of the stringent requirements of the programs, but even so, it seems likely that there were enough uninsurable people to provide many anecdotes, but not much data.OverallThough these specific groups saw the greatest improvements in insurance access, the ACA has done enough to have an impact on the overall population. In the previous graphs, you’ve probably noticed that nearly all of the lines were going in the right direction. Here’s the overall numbers, with as much context as changes in the CDC survey permit; keep in mind that ACA passed in 2010 and most provisions kicked in during 2014.The first 13 years of this century were characterized by people falling out of the private insurance market and landing either in public insurance or outside of any insurance at all. The introduction of the ACA marked a sharp turning point where the uninsured began to fall rapidly, and though some of them moved to public programs, most reentered the private insurance market.These are the kinds of numbers you would hope to see if the ACA is going to do what it was intended to do.Storm Clouds on the HorizonUnfortunately, the story is not quite that simple. While the Medicaid expansion is working alright, the insurance exchanges—the mechanism meant to increase coverage of middle-class individuals who aren’t insured by an employer—are experiencing some issues. And although they are minor right now, they could presage a massive failure of a crucial mechanism.The Troubled ExchangesThe ACA includes exchanges (the “Health Insurance Marketplace”) on which those who are not eligible for Medicaid can purchase private insurance plans. It also includes subsidies for the least wealthy exchange customers; the subsidies gradually decrease until you reach 400% of the poverty level, at which point you must pay the full price of your premiums.Subsidies are calculated based on the premium of the second-lowest “silver”-tier plan on the exchanges in your area, so the price of that plan is very important. And on the whole, the premiums on these plans seem to be rising.The above chart is a composite of data from two different reports, and I can’t recalculate their weighted average for all three years. However, the preliminary 2017 report indicates that in 2016, on average premiums for these plans rose 5%, whereas in 2017 they look to be rising 9%. A final report for 2016 covering more cities indicated that premiums rose 3.6% in 2016, versus -0.3% in 2015. The -0.3% and 9% numbers can’t be directly compared, but looking at both pairs together, this looks like premiums are not only growing each year, but the growth is accelerating.Accelerating premium growth could be an issue for the subsidies. The ACA includes a cap on the total amount of the subsidies it pays. That means that, if costs continue to grow, eventually the subsidies will not keep up with that growth. Costs will rise for the lower middle class, pushing them out of their insurance plans.Another worrying sign for the exchanges is that the number of insurers participating in each market appears to be falling.Unlike the previous chart, here we do have coherent average numbers (they’re the first set of bars), and they clearly show that insurers are pulling back.Why? Insurers say these plans are operating at a loss, because the patients they’re enrolling are sicker than they expected. I touched on this earlier, when I was talking about getting young people to participate in the insurance market:Health insurance works by having many healthy people pay for a few sick people. If there aren’t enough healthy people, each of them will have to pay more.What we are seeing is that sick people are signing up for insurance through the exchanges, while healthy people are avoiding them. Some insurers are responding by raising prices, but this will likely drive away some healthy people, making the insurance pool even sicker. Other insurers are leaving the exchanges entirely because they have concluded they simply can’t make it work there.That’s a very, very dangerous sign, because it indicates that the forces at work in the private market are out of balance in a way that might accelerate.A Pair of SticksEarlier, I mentioned that the ACA aimed to help people with pre-existing conditions get health care. To do that, the ACA imposed guaranteed issue and community rating rules: insurers must enroll all applicants regardless of health status, and must offer the same price to all enrolled individuals. In other words, the government forced the insurance companies to accept all comers, no matter how risky they are.This has an obvious danger, however: People could cheat the system by enrolling only when they needed medical care. For instance, a person who needed an expensive knee surgery could sign up for an insurance plan, pay the premium while they’re getting the surgery and physical therapy, and then cancel the plan afterwards. If you think about the “many healthy people paying for a few sick people” model, this is a worst-case scenario: almost everybody is sick, so the sick people are basically just paying their own bills.To prevent this, therefore, the ACA provides two reasons not to cheat.The first is the enrollment periods. You cannot buy insurance on the exchanges just any time you feel like it; you must either buy it during the open enrollment period, which runs through the end of January, or during a special enrollment period, which is triggered by certain changes happening in your life, like getting married, moving, or losing an employer’s insurance benefit. This makes cheating much riskier: If you decide not to get insurance in January and then find out you have cancer in March, you could be dead before you can see a doctor.The second is the mandates. The employer mandate requires most employers to provide insurance to most of their full-time employees, while the individual mandate requires individuals to have health insurance. If they don’t, the IRS will assess a special penalty against them. (For legal purposes, this is technically a special tax.)In theory, these two mechanisms should force everybody to have health insurance, so nobody can cheat. The problem is, so far they haven’t been strong enough. It’s too easy to trigger a special enrollment period by marrying a long-time boyfriend/girlfriend or moving in with a relative; it’s too easy to evade the employer mandate by shaving a few extra hours from part-time employees’ schedules; and it’s too easy to ignore the individual mandate because if it’s not paid, the only consequence is that it’s deducted from any tax refunds—the usual consequences of failing to pay taxes don’t apply.How do we know these are issues? Because the administration has tightened the rules about special enrollment periods. Because the number of workers working just below 30 hours per week is rising, while the number working just over 30 is falling. Because nearly a third of the people taking the penalty could get insurance for the same price or lower.And ultimately, we know these are issues because the uninsured rate is not dropping sharply enough among less-insured demographics. Let’s take another look at that age chart from before:Previously, I pointed out that the 18–24 line has declined steeply because of the young adult coverage provision. But the 25–34 and 35–44 lines have not. We want these relatively more healthy age groups to take up insurance more quickly than the 45–64 group, increasing the number of healthy people whose premiums can support the sick. But instead, their lines are running roughly parallel to their elders.(The 25–34 line is a little steeper than the others, but of course 25-year-olds are covered by the young adult provision, and the Medicaid expansion also targeted the young end of this age group.)In other words, the government has one set of sticks it’s using against the insurers to make them enroll everyone who asks, and a different set of sticks it’s using against individuals to force them to enroll with an insurer. But the sticks being used against individuals aren’t as sturdy as the ones being used against insurers, and so individuals aren’t doing what’s needed for the exchanges to work properly.Now, those sticks are getting sturdier. As mentioned, the government has made the rules around special enrollment periods more stringent, and the individual mandate’s penalty will only reach its full amount this year. But so far, they have not been enough, and it’s not clear they can get strong enough without action by Congress.The Death SpiralIf the mandates and enrollment periods are not strong enough, there’s a serious danger the market for individual coverage will enter a death spiral. (Yes, that’s really the technical term.) As the pool of insured people gets sicker, premiums will have to rise. This will cause more healthy people to give up their insurance, making the pool still sicker, and repeating the process. Eventually individual insurance will be too expensive to be cost-effective for anyone, and people will have to get covered by employers or do without insurance.This sounds like a farfetched scenario, but it has happened repeatedly when individual states tried to implement guaranteed issue and community rating rules. A “friend of the court” brief filed in support of the ACA described this to the Supreme Court:…prior reforms in Kentucky, Maine, Massachusetts, New Hampshire, New Jersey, New York, Vermont, and Washington that prohibited risk-based underwriting but did not require the purchase of insurance or provide other significant incentives for obtaining insurance resulted in markets with “death spiral” characteristics.In Washington, for example, the Legislature reformed the individual health insurance market in 1993 to guarantee that residents could purchase insurance based on community—and not individual—rates. During the first three years, premiums in Washington’s individual health-insurance market increased by 78 percent. Enrollment fell by 25 percent. By September 1999—six years after the reforms had been introduced—all but two of the State’s nineteen private health insurers had withdrawn from the market, and the last two had announced their intention to withdraw. “[T]he individual market had essentially collapsed.” Washington repealed the market reforms in 2001.New York experienced a similar dynamic. In 1992, the Legislature reformed the health-insurance market by guaranteeing the issuance of insurance at community-based rates. These reforms prompted a “sharp decline” of the individual insurance market. In 1992, 1.2 million New Yorkers purchased individual insurance policies. But premiums had increased 35–40% by 1996. By 2010, only 31,000 New Yorkers remained in the individual insurance market—a decrease of 97%. At that point, the only people who participated in the market were those who were “very sick (and affluent).” Those reforms thus made health insurance cost and availability considerably worse, rather than better, and the flaws of those failed attempts are now well understood.Before we get too excited, let’s put this in perspective: The premium increases we’ve seen so far have not been anywhere near 78%. The average exchange has lost 1.1 of its 6.9 insurers, not 17 of 19. And thus far, coverage through the exchanges has not fallen at all, let alone by 97%:(When reading this chart, note that the open enrollment period creates a spike each Q1, so you really have to compare numbers to the corresponding year-ago quarters.)Still, these indicators are moving in a direction that the ACA’s supporters did not anticipate, and one which is consistent with a serious, known failure mode the ACA was designed to avoid. It is hard to see this as a good thing.The Rock and the Hard PlaceIf the enrollment periods and mandates truly are too weak, an act of Congress could strengthen them, which in theory ought to correct the issue. However, doing so would be politically difficult.I will present three different scenarios, depending on how the election goes down.Scenario Red: President Trump and a Republican CongressI will assume that Trump doesn’t start a nuclear war or do any of the other extremely rash and destructive things Democrats fear he will do. Maybe Paul Ryan put a leash on him.With the ability to pass any legislation they please, the Republicans will want to repeal the ACA, but they will quickly run into a difficult problem: What will they replace it with? Certain parts of the ACA, like the young adult provisions, are quite popular. And unfortunately for them, guaranteed issue and community rating are among the popular provisions—but the individual mandate needed to implement them is one of the most hated among Republicans.The solution may simply be to gut parts of the bill that only appeal to liberals (the Medicaid expansion, the contraceptive mandate, the (failing) insurance co-op provision), make some cosmetic changes to the core middle-class insurance market mechanisms, and declare victory. Essentially, they’d just be taking ‘Obamacare’ and putting fifty-foot gold letters spelling “TRUMP” on the top. It wouldn’t be the first time.This scenario could be considered a success for the ideas at the core of the ACA, but it certainly wouldn’t be a success for the Democratic Party or the delicate work to build a coalition behind the ACA as passed in 2010.Scenario Purple: President Clinton and a Republican or Divided CongressCongress will continue the game with Clinton that they began with Obama in 2011. Republicans will try to pass bills to repeal the ACA, which will fail. Clinton will take various actions to try to embarrass Congress into cooperating, which will fail. Both sides will accomplish little through these actions except rallying their respective bases.If a death spiral begins to occur, Clinton will implement various measures, of increasingly dubious legality, in an attempt to slow or stop it. They are unlikely to succeed. She will ask Congress to fix it, but they will send her more repeal bills. Meanwhile, the individual insurance market will slowly destroy itself. Eventually either Clinton will cave or the exchanges will crater entirely.In 2020, Clinton will try to blame the carnage on the Republicans, but this will fall on deaf ears. After all, the ACA was conceived, legislated, and executed wholly by Democrats; all the Republicans did was try to keep them from going through with their foolish plan. Clinton will likely be crushed in her reelection campaign, unless the Republican base makes an even stupider decision when nominating. David Duke, perhaps.Scenario Blue: President Clinton and a Democratic CongressAn all-Democratic federal government will finally be able to tweak the ACA, smoothing many of the wrinkles and incorporating some of the ‘creative’ interpretations the Obama administration used to work around mistakes into the law. For instance, they would almost certainly patch the gap in the subsidies created by Republican state legislatures unexpectedly refusing to implement the Medicaid expansion. They might even enact a public option in an unconvincing show of Bern-feeling.However, they will not want to touch the individual mandate. The mandate is arguably what limited their last majority to a single term; they will not be eager to repeat that experience.If a death spiral begins, though, they won’t have much of a choice. Oh, they’ll try to delay it; they might even implement some stopgaps which will put it off for an election or two. But sooner or later, they’ll either be forced to strengthen the mandate, or to enact a much larger reform and effectively concede that the ACA was a mistake.(Incidentally, introducing a public option would not arrest the death spiral; it is not caused by insurers seeking profit, but by insurers seeking to cover their losses. A public option would cease to be politically viable if it generated huge deficits, which is what would happen if it tried to hold down prices in a death spiral.)No matter how they addressed a death spiral, the meltdown of the ACA on their watch would be an electoral disaster for the Democrats. If it happens before 2020, Clinton will likely be a one-term President. And then, of course, the Republicans will have a crack at the ACA; I already discussed what that would probably mean.ConclusionIn terms of expanding coverage, the ACA is currently succeeding very well among the subgroups it specifically targets and moderately well in the population as a whole. There are fewer uninsured Americans today than at any point since 1997, which probably means there are fewer uninsured than ever before.However, the prospect of a death spiral casts a pall over this apparent success. If one occurs, it will most likely spell the end of either the ACA or the Democrats’ chances in the next election. Would the Democrats consider the law a success if it threw them out of power not just once, but twice? I’m not so sure—but that’s an answer to a different question.In short, it’s too soon to tell whether the ACA is a success or a failure. But sitting here in 2016, what we can say is that we have narrowed the set of possible outcomes. The ACA did not cause costs to drop like a stone*; nor did it force the nation’s elderly to file through death panels; nor did it achieve perfect, universal coverage; nor did it lead inexorably to single-payer. It seems like there are two possibilities left: modest success at achieving many of its goals, or a critical miscalculation in a crucial part of the bill with costly political consequences.—* I’m up against the deadline, so unfortunately I don’t have time to deeply explore health care cost control, which was the other major goal of the ACA. In brief: the US spends a lot more on health care than other countries, and the ACA included many experiments in ways to reduce those costs. Most of these experiments have failed. However, the growth of costs seems to have slowed—where it used to be around 10%, it is now around 5%—even as more people are getting insurance. Some of that may be the economy, but some of it is probably the ACA. That doesn’t get us any closer to paying the prices for health care that Britain enjoys, but it’s an improvement over the status quo.

The Gist: The overall criticisms of the program are its inefficiency, inaccuracy, and monetary cost. The inaccuracy claim comes largely from the fact that risk assessments are subjective, and therefore biased. Scientists use bioassays, which often give conservative estimates of environmental risk. They also use epidemiology, an assay that makes it hard to link observed risk with cause.[1] One of the biggest controversies of the program is the liability issue. The EPA states that if negligent and fault is found on the part of the defendant, that they are strictly held to the funds of cleaning up the site; however, many worry that it actually tax dollars paying for the doings of these highly profitable companies. One of the unique properties of the Superfund is that companies that dump(more)