There is always a difference between outputs and outcomes, or as Milton Friedman once put it: “One of the great mistakes is to judge policies and programs by their intentions rather than their results.” Every program is sold to the public on its good intentions, but any fair evaluation should wait until the actual results are determined. This is especially important for controversial government programs such as the Patient Protection and Affordable Care Act of 2010, more commonly known as "Obamacare." Before Obamacare was signed into law, conservatives were quick to label it as job-killing and a socialist takeover; liberals celebrated it as a long-overdue triumph over the nation's health care problems. By early 2016, Obamacare had evolved much like any other government venture, too ambitious in its pitch and burdened with unexpected hurdles.

What Was Promised

President Obama was confident that, by the end of his run as commander in chief, his universal health care bill would "cover every American." There were approximately 40 to 42 million uninsured Americans at the time, according to the Congressional Budget Office (CBO). After the bill was passed, estimates were revised, but a full 22 million people were still expected to enroll in Obamacare exchanges by the end of 2015.

During the run-up to the votes for Obamacare in Congress, the administration claimed the cost of health care would go down by $2,500 per family. The plan was also supposed to save the country money or, at least, be revenue neutral. As Obama said in 2010, "I will not sign a plan that adds one dime to our deficits -- either now or in our future."

For those with good existing coverage, Obamacare created a "grandfathering provision" to allow companies to keep selling older plans. Promises were made regarding no cancellation of current plans, no cost increases for present family or employer plans, and easy-to-use and competitive state exchanges for those looking for plans.

Challenges and Changes in the Rollout

It is very common for government programs to undergo changes during their rollout phases. Businesses, lobbyists, regulators and politicians react to new and unexpected changes by issuing other rules, often to try to prop up a program's popularity and avoid bad publicity. As of January 2016, there have been dozens of changes to Obamacare, according to the Galen Institute, a nonprofit health and tax policy research organization.

Some changes were delays administered directly by the Obama administration. These included a delay on the employer mandate, the individual mandate and penalty; the online SHOP exchanges; the sign-up deadline for the program; the low-income Basic Health Program; and extensions of credits or subsidies to parties affected by a slower-than-expected implementation.

Congress repealed free-choice vouchers and cut Medicaid benefits to senior couples earning $64,000 or more per year. Funding was cut to programs and agencies, including the IRS, that were designed to implement Obamacare. The government has arbitrarily changed premiums and calculations for the so-called "risk corridor," which was set up to split profits and losses between private insurers and the Department of Health and Human Services (HHS). The government knew lots of insurers would struggle to pay for all of the extra coverage so the HHS was initially allowed to absorb up to 80% of losses; the actual figure paid out has been less than 15% of losses in 2014 and 2015 since losses were much higher than expected.

The Results Thus Far

Obamacare has been successful by one metric: the number of uninsured Americans plummeted by 8.8 million in the first year and a half after the rollout, according to U.S. Census data. This still left 10.4% of the population, or 33 million, without insurance, but that is down from 13.3% at the end of 2013.

After 2013, both PolitiFact and the Washington Post Fact Checker declared the administration's claim "If you like your health care plan, you can keep it" as the Lie of the Year. It turns out the "grandfathering" strategy had all sorts of rules and restrictions and many older plans lost their grandfather status. made its debut on Oct. 1, 2013; HHS began sending out cancellation letters to insurance customers the very same day.

Rather than saving $2,500 per family in health insurance costs, the real cost of insurance skyrocketed after 2010. A 2015 Kaiser study found that, for employer-sponsored plans, premiums rose nearly $5,000 since the passage of Obamacare. The same study showed that average deductibles nearly tripled since 2005 to $1,077. Even family plans rose a modest 3% per year since 2010.

The large spike in premiums is probably the least surprising effect of Obamacare. It is simple economics; millions of new people are looking for more medical care than they did before, but there is nothing in the law that magically creates extra hospitals, doctors, medical equipment or insurance companies. The supply of insurance and medical care stayed the same, or shrank in many instances, but the demand shot up considerably; prices had to rise.

The spike in premiums is probably not as large as it could have been. Just 9.9 million people had signed up for Obamacare by the end of 2015, less than half of the original estimated number. Eighty-seven percent of these were subsidized, meaning taxpayers are picking up the tab for the vast majority of new Obamacare customers. Several of the state co-ops failed to get off the ground, and several of those that did start closed or planned to close by 2016, including in Nevada, Louisiana, Iowa and Nebraska.

Obamacare enrolled millions of Americans who previously had not purchased health insurance. The pool of insured is still smaller than expected, sicker than expected, older than expected and costlier than expected. Premiums and health care costs have not fallen as expected but instead rose far faster than the rate of inflation; the CBO estimates Obamacare will add $353 billion to deficits by 2025. There is no guarantee the landmark health care law will not eventually turn around and realize the promises of 2010 in some way, but as of 2016, there is still a big difference between Obamacare's outputs and outcomes.

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