With enemies like John Boehner, a president hardly needs friends.
“Our drive to stop the train wreck that is the president’s health care law will continue,” the House Speaker blustered Wednesday night after failing yet again to derail, defund or even delay the Affordable Care Act. With their latest assault on Obamacare, Boehner’s House Republicans have not only emasculated their own party but boosted public support for health care reform. With the shutdown and the threat of a default now behind us for the moment, the greatest expansion of the social safety net in a half century is set to proceed on schedule.
But anyone who cares about the future of health care should keep this week’s win in perspective. The Tea Party Republicans may pose a diminishing threat to reform, but their humiliation this week is no guarantee of success. Obamacare has transformative potential, but the political battles will continue. Here are some the pressure points the administration and its allies will have to navigate in the weeks and months ahead.
Engaging consumers
As most of the government was grinding to a halt on Oct. 1, new federally mandated marketplaces for health insurance were opening for business in all 50 states. When these online “exchanges” are functioning properly, they’ll extend affordable coverage to tens of millions of Americans who have long been frozen out of the system because they lacked employer-sponsored health plans. Every plan will cover the same essential services, enabling consumers to shop for value. People with “pre-existing conditions” will pay the same rates as everyone else, and older adults will pay no more than three times as much as younger ones. Most folks will pay less than $100 a month after tapping the subsidies that Obamacare provides for anyone living between 100% and 400% of the federal poverty level.
This all assumes that the online exchanges will work as advertised, and that millions of uninsured people will have the tools, the skills and the motivation to use them. Those are iffy propositions at the moment. The launch of 51 electronic marketplaces was bound to be glitchy, but consumers have spent days, if not weeks, stranded on websites that won’t let them create user names and passwords, let alone process applications and calculate available subsidies. The Department of Health and Human Services (HHS) swears the 36 federally-facilitated exchanges are working better by the day, but it has yet to detail its progress or publish a timeline for repairs.
The heat is sure to increase now that the shutdown drama is over. Republicans in Congress have seized on the widespread technical failures, accusing the administration of gross incompetence and demanding that HHS Secretary Kathleen Sebelius resign or be fired over them. The issue could weaken public confidence and keep the president on the defensive during a critical period, but the glitches themselves are unlikely to derail health care reform. Consumers have until December 15 to buy coverage that starts in January, and the open-enrollment period continues through March. If people are enrolling effortlessly by Thanksgiving, the exchanges should have no trouble meeting the Congressional Budget Office projection of 7 million enrollments by March 31. Some 14.6 million people visited healthcare.gov during the first 10 days of October, and health care experts predict that many will be back.
Outlasting the resistance
But even if most of the exchanges succeed, GOP resistance could hobble them in certain parts of the country. Some 26 states—24 of them led by Republicans—have refused to help build or manage their online marketplaces, forcing the feds to do the job for them. Many of those states are sabotaging the federal efforts by restricting efforts to engage and educate consumers. Besides subjecting official outreach workers to fees, tests and other burdensome formalities, at least 11 states have passed laws that bar ordinary citizens from helping each other shop for coverage. The restrictions are legally and constitutionally suspect, as Tennessee recently discovered, but few have been challenged in court.
Right-wing political groups are also spending millions to convince young adults that they should forego health coverage despite the new legal mandate to sign up. The message will be a hard sell if the target audience can get online to compare the advantages of enrollment (low rates, generous subsidies, a hedge against financial disaster) with the thrill of “burning your Obamacare card” (which doesn’t technically exist). It’s too early to gauge the effect of all this noise, but the evidence from one state is heartening. Of the 1,157 people who applied for coverage through Connecticut’s new marketplace, Access Health CT, during its first week online, nearly a third were under 35 years old.
Filling the gaps
While fighting off attacks on the exchanges, health care advocates also need to regroup on the issue of Medicaid expansion. As signed into law three years ago, the Affordable Care Act was set to extend health coverage to 17 million impoverished adults who’d been frozen out of their states’ overly restrictive Medicaid programs. Medicaid and its companion initiative, the Children’s Health Insurance Program, have brought care to millions of low-income kids in recent decades. But states have long denied coverage to adults without children, regardless of their need, and many have excluded parents making more than a fraction of the federal poverty wage. Nationally, Medicaid covers only three out of 10 poor adults.
In its original form, the Affordable Care Act extended Medicaid eligibility to all adults living below 138% of the federal poverty level, with or without kids. The states had to honor the standard, but the law provided full federal funding for the first three years of the expansion and funding of at least 90% after that. The Supreme Court foiled the plan in June 2012, when it ruled that states could opt out of the expansion. Roughly half of states—including many of the poorest and most underserved—boycotted, and the consequences are now at hand.
Though many Republican governors have opted out reflexively, fearing the wrath of the right, some have done the math and realized they can’t afford the gesture of contempt. Arizona’s Jan Brewer, New Jersey’s Chris Christie and Michigan’s Rick Snyder have all bucked party orthodoxy to cover their neediest citizens and strengthen their economies. Florida’s Rick Scott tried to join the trend last winter, only to cave when his fellow Republicans balked in the legislature. Ohio’s John Kasich plans to sidestep a similar roadblock next week by pushing a Medicaid expansion measure through the body’s controlling board.
The new Republican rationalists are still outnumbered by die-hards like Rick Perry of Texas. But that could change as their constituents see what they’re missing next year. Texas could reduce its uninsured population by half if it added Medicaid expansion to Obamacare’s other features. The expansion alone would cover 1.2 million low-income Texans, largely at federal expense, while saving the state $1.7 billion in unpaid medical bills over the next decade. The expansion would also net Texas hospitals nearly $25 billion in Medicaid payments by 2023.
“I saw it as the most important health care opportunity in a generation,” says Clay Jenkins, the “judge” (or chief executive) of Dallas County. “Our chamber of commerce, our hospital association, our interfaith alliance and many others came together to ask the governor to accept our share of those federal dollars. By declining, he denied health coverage to more than a million eligible Texans. By accepting, he could have helped every taxpayer in the state.”
Whatever their feelings about the poor, red state citizens will soon discover they’re paying federal taxes to expand health care and stimulate economies in places like California and Oregon. If health advocates can tap that dismay—and point it in the right direction—the politics of health care could change quickly, and the Affordable Care Act could have another triumphant year.
Geoffrey Cowley