Obamacare just got real.
Sure, there were some new rules and benefits over the last few years, but that was just a warmup. Starting today, all of the big pieces of the Affordable Care Act — the biggest domestic achievement of Barack Obama’s presidency and one of the most far-reaching changes in American social policy in decades — go into effect. And Americans will start to see, for better or worse, how the law really works.
Private health coverage starts for more than 2 million Americans who managed to get through that federal enrollment website or the state-run versions. People with pre-existing conditions can’t be turned down anymore. Subsidies will start to help low- and middle-income people pay for their insurance.
The expansion of Medicaid begins, and as many as another 3.9 million low-income Americans are in line to get that coverage. And yes, the individual mandate kicks in to require just about all Americans have some kind of health insurance or pay a fine.
But it’s only going to be accepted as a “big deal,” as Obama put it before the holidays, if the rest of America decides it was worth the trouble. The Affordable Care Act has already survived a series of near-death experiences, from the rocky passage to the Supreme Court challenge in 2012 to that enormous self-inflicted wound known as the HealthCare.gov rollout. Now, it has a whole new series of hurdles it has to clear.
Obamacare supporters and the president and his team can bask for just a moment in the glow of their long-sought goal finally becoming law — but only for a moment. The ACA’s Perils of Pauline debut is going to continue. Here are the obstacles ahead this year:
The big challenge: Changing the narrative
After three solid months of “botched rollout” stories, Democrats will have to hope that the reality of new health coverage for millions of Americans will be enough to outweigh the disruption the law is causing to millions of others.
Even now, top Democrats are convinced that, at some time during the year, there will be a natural tipping point. Enough people will either have coverage through the law or know someone who’s benefiting from it, they say, that Democrats will be able to put Republicans on the defensive about wanting to take their benefits away.
Joel Benenson, Obama’s pollster, is already playing down the threat of any lasting damage from the rollout. He insists that most Americans “want leaders in Washington taking actions that will strengthen their economic security and keep growing jobs and our economy” — a signal that the administration still believes the Affordable Care Act can be part of a broader economic security message.
“The only people obsessed with the ACA rollout today are Washington insiders,” Benenson said in an email, noting that “we have had a presidential campaign and a year in Congress where those who advocated for repeal of Obamacare lost.”
Other Democrats are quicker to acknowledge that the last few months have hurt the Obamacare cause. But they still believe the politics will turn around when more people have health coverage who could never get it before, especially people with serious health problems.
“The hard reality is that, particularly in October, the vast majority of people who tried to sign up had a terrible experience,” said Democratic Rep. Rob Andrews of New Jersey. And “if I had one thing to do over again,” he said, it would have been to give the people with substandard individual health plans a warning that they’d have to upgrade — saying, in effect, that “you can still buy a car without seat belts and airbags, but that day is going to change.”
But over the course of 2014, Andrews said, it will be clear to most Americans that the law doesn’t touch them — so Republicans who keep attacking it as a fundamental threat to their health care will have “a Chicken Little problem.”
Republican pollsters aren’t so sure about that. The storyline of government incompetence and disruption is so firmly in place by now, they say, that even if Democrats could line up a series of “don’t take my benefits away” events with cancer survivors and other sympathetic people, it wouldn’t make a big difference.
“There’s a very big filter that’s been locked into place, so the amount of information that would be required to break through that filter would be substantial,” said Republican pollster Bill McInturff.
Starting the coverage
The first specific hurdle the health care law has to clear, starting today, is the beginning of private health and Medicaid coverage for millions of Americans. It has to start smoothly, without a lot of horror stories of people showing up at doctors’ offices without coverage or being confused by what’s actually covered.
And, of course, Obama administration officials are hoping they’ve done enough to get through the next few weeks without a “coverage gap” — people who are suddenly uninsured because they couldn’t replace their canceled policies in time.
They’re hopeful that, between people’s ability to renew directly with their insurers, a better and faster federal website to enroll others, extensions of old health plans in some states through Obama’s administrative fix, and slimmer “catastrophic” health plans for people who can’t get those extensions, they’ve given people plenty of options to replace their coverage. But they’ll be watching closely, just in case.
Even if they can get through the first few weeks without more fires breaking out, they’ll have to turn to the next phase of the debate, which will turn on whether more people think they got good deals or pricey health plans without enough doctors.
“It will be a more granular-level debate that will focus on the price and the quality of the plans,” said former Obama spokesman Ben LaBolt. “Republicans will focus on people whose costs went up, Democrats will focus on people who didn’t have coverage before who had it now.”
White House officials say they’re planning to keep up the recent blitz of events promoting the benefits of the law, working with advocacy groups to highlight people who have gained coverage.
LaBolt also predicted that, once insurers start spending money to promote the law — which is now starting to happen — some of the advantage opponents have enjoyed through their well-funded advertising campaigns will start to disappear. “That landscape is about to change,” he said.
But Republican pollster David Winston, who advises the House GOP leadership, says the administration still faces a big danger from people who believe the law is hurting the quality of their own care — and that Obama won’t be able to regain the credibility he lost with the broken “you can keep your health plan” promise.
Enrolling enough people
By the end of March, there will be another moment of suspense: Can the Obamacare health insurance exchanges enroll enough people — or at least the right mix of people?
The open enrollment period for 2014 ends on March 31, so there could be another wave of last-minute signups. But the administration has been backing away from its early suggestions that 7 million people would be the goal for the exchanges — a number that came from the Congressional Budget Office estimate of how many people would enroll in the first year.
Instead, they’re now saying that even a smaller number would be fine, as long as there are enough young and healthy people to keep the health plans financially stable.
And even though it’s not clear yet whether that’s happening, they’re convinced that it will happen by the end of March, because they expect a big wave of people to sign up at the last minute — mostly people who didn’t have any reason to enroll earlier.
“We are focused on the long game for March 31,” said one White House official, because the experience of Massachusetts — which paved the way for Obamacare with its own health reform law in 2006 — “shows that people come in at the end.”