The Looming Challenges for Obamacare in 2013

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How quickly the politics of health care has changed. Just over a month ago, the country was debating whether President Obama's health reform law, aka "Obamacare," should be saved or scrapped. Now, with the president's reelection, that's all settled, and regulators, states, employers, and health care providers are rushing to get ready for a transformed system that is coming in 2014.

This involves several challenging tasks. Industry is readying itself for hundreds of pages of regulations, insurance companies for new products and some 7 million new customers in the first year, states for an IT infrastructure unlike anything they have seen. Employers are facing a raft of new requirements, including an obligation to cover all of their workers or pay fines for not doing so. Congress's role is minuscule. House Speaker John Boehner acknowledged as much days after the election, when he said that Obamacare is "the law of the land" and that repeal efforts were over.

But the lingering uncertainty around the law -- and its expansive ambitions -- means that the work to be done between now and January 2014 is enormous.

Public Education

Some 50 million people in the United States are without health insurance, and nearly 40 million of them stand to benefit from the law. In states that choose to expand their Medicaid programs, all residents who earn below 133 percent of the federal poverty limit, about $15,000 annually for a single person, can sign up for the federal-state Medicaid program. And in every state, people of moderate income will be eligible for tax credits to help them buy health plans on regulated public marketplaces, called exchanges.

Getting those marketplaces built and the states ready to accept a flood of applications are big challenges. Perhaps a bigger one is reaching all those eligible people and educating them about how they can benefit. Although public polling has shown consistent and strongly held views about the health law overall, public understanding of its individual provisions has always been low. A recent survey conducted by the newly formed Enroll America found that 83 percent of people who will be eligible for Medicaid were unaware of their status, as were 78 percent of those eligible for tax credits.

"I can't think of any task that involved changes in America's health care system over the last half-century that is as big a challenge as reaching these tens of millions of people," said Ron Pollack, the executive director of Families USA, a health-reform advocacy group that has joined forces with the health industry and charitable groups to form Enroll America.

Enroll America is hoping to raise "tens of millions of dollars," according to Executive Director Rachel Klein, money that will be devoted to television and online advertising, as well as word-of-mouth education that can reach the uninsured in their communities. The group, which draws on resources from health insurers, hospitals, and religious and community groups, will conduct a nationwide push, with a greater focus in the states with the largest population of uninsured residents.

The healthy people the system will need are the ones who will be hardest to reach.

Enrollment levels will matter, because the number of Americans the law insures will largely determine whether the Affordable Care Act is considered a success or failure. But enrollment levels will also determine whether the law's basic apparatus will work. The Affordable Care Act is designed to bring young, healthy people into insurance markets, where they can help offset the costs of insuring the old and the sick. Populations that are already in constant contact with the health care system will be encouraged to sign up for insurance as soon as they can. But the healthy people the system will need are the ones who will be hardest to reach. Without their participation, the law may not succeed in making coverage affordable for the uninsured.

The federal government will be involved in the public outreach, and it is developing a strategic plan, built on its enrollment efforts after the enactment of the Children's Health Insurance Program in 1997 and Medicare Part D in 2003. Political considerations, however, might limit the government's efforts. House Republicans have already called for an investigation into the decision to devote government funds to the promotion of the health care law. To critics, such advertising smacks of political advocacy.

The role of states may be more variable. In Massachusetts, the only state to have rolled out a similar system of expanded coverage so far, politicians and the business community pulled together in support of the law, and a clever advertising campaign, linked to the Boston Red Sox, told young, healthy, uninsured residents that they should buy insurance. More than 95 percent of the state's residents are now insured. Several people involved in the effort say that the marketing campaign, and the uniformity of the public message about the law, were key to its success.

But not every state is Massachusetts when it comes to health care reform. "The question is, in Mississippi, do they run those ads, and does somebody from the tea party get on afterwards and say, 'Stick it to the government. Pay a penalty instead.' " said Jonathan Gruber, an MIT economist, who worked on the Massachusetts and federal plans.

A few states have begun their own advertising and public-education campaigns. California, Maryland, and Washington, among others, have already started planning their pushes. Yet many of the states that are resisting the health care law -- refusing to build their own exchanges or to expand their Medicaid programs -- are those with the largest uninsured populations. Those states already tend to have lower-than-average rates of participation in Medicaid by populations that are currently eligible, suggesting either cultural resistance to public assistance or systems that have discouraged enrollment. Those factors suggest greater challenges in bringing uninsured people into the health care system. "There may be unevenness from state to state," Pollack said.

States

Another challenge is creating and supporting the online marketplaces where individuals will find the insurance plans. Nine states have refused to expand their Medicaid systems to cover new populations -- leaving a gaping hole in those states' coverage expansions. About 20 have decided not to help build the state insurance exchanges where individuals will be able to shop for plans. The federal government is planning to intervene in those states and install its own exchanges, but it's clear that uncooperative states will be able to throw a few wrenches into implementation.

When individuals come to seek insurance, they will be interacting with brand-new systems. Aside from Massachusetts, no state has built the kind of regulated online insurance marketplace outlined in the health care law. The idea is for each state to have a website similar to what Kayak is for travel: People will go online, answer a series of standardized questions, and immediately find out what insurance plans they can purchase and what financial assistance they qualify for.

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Margot Sanger-Katz is the health care correspondent at National Journal.

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