Obamacare Deadline Q&A: Where We Are, What's Next

Obamacare Deadline Q&A: Where We Are, What's Next
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After years of anticipation, a long spell of calamitous implementation, and millions of hours spent by advocates nudging a nation to “get covered,” the Obama administration will cross a health-care threshold on March 31.

The arrival of Monday’s deadline to get private health coverage (backed by federal subsidies for those who qualify) won’t be the final word on President Obama’s most controversial legislative achievement. Indeed, clashes between Democrats and Republicans over Obamacare will shift into another election-year phase.

Obama’s hallelujahs that more than 6 million people have enrolled nationwide, along with millions more under Medicaid (plus an unknown number who purchased their coverage directly from insurers), will dominate White House messaging this week.

Critics of the Patient Protection and Affordable Care Act, however, have no intention of muting their warnings of costly complications ahead. And the public, still refereeing, will likely be as confused as ever. To lay out the issues in play, and look ahead to what’s in store, RCP offers this Q&A clarifier. 

How will the law's success or shortcomings be measured, and when?

President Obama, joined by Health and Human Services Secretary Kathleen Sebelius, says the benefits of the reform law are already evident and projected to grow over time, particularly because of Medicare’s powerful influence on the U.S. health care system.

They point to slowed growth in health care spending, which bolsters the nation’s balance sheet. The law’s demands for less waste and incentives for health outcomes rather than medical procedures are just now rippling through hospitals and physicians’ practices, and from insurance companies to executive suites. Because the law also aimed to improve preventive care, extend insurance to more people beginning in 2014, and deliver it at more affordable prices across states, the overall impact of the ACA cannot be measured for years, according to economists.

Getting more than 6 million people to enroll for new insurance over six months was a formidable achievement, but it remains meaningless without an understanding of who is newly insured, how their health profiles impact providers and insurers (and the risk pools), and how consumers, employers, insurers, health care providers, and governments -- state and federal -- adapt going forward.

What do enrollment totals in 2014 tell us, and what key information remains murky?

So far, the government has counted people who signed up to buy insurance, not the number of people who are actually insured. To be insured via the exchanges this year, consumers had to pay their premiums, and one independent survey found that one in five people failed to do so before Jan. 1. The government has not released that data, nor has it broken out how many people who had no insurance at all enrolled to buy coverage. Critics say most of the people who enrolled for coverage were not uninsured, but opted to change their plans. Officials said more detailed data would be released later this spring.

Despite the federal requirement that nearly everyone have insurance in 2014, and the ACA’s threatened fines for those who do not, estimates and polling suggest states and the federal government have not overcome the problem of the uninsured. They have been among the hardest to reach and motivate, and remain among the most uninformed about the law.

In addition, the government says it has not been able to reliably identify how many Latinos and African-Americans have enrolled for coverage -- key targets, according to health care advocates -- because the marketplaces were not uniform in asking about race and ethnicity.

After the March enrollment deadline, what's the next hurdle for implementation of the law?

Insurers must decide based on their experience this year how they’ll price policies in 2015. Sebelius conceded in testimony before the House Ways & Means Committee this month that insurance prices will rise next year, but she said the hikes would be smaller than experienced since the ACA’s enactment in 2010. Analysts point out that participating insurers will decide on their policy premiums and deductibles just a few months before voters go to the polls this fall. And on Nov. 15 -- less than two weeks after Election Day -- open enrollment begins in the marketplaces for next year’s offerings.

The administration has denied it will delay or void the individual “shared responsibility” mandate that requires most Americans to have “minimal essential coverage” this year. The penalty for not having insurance, levied through the Internal Revenue Service at tax time in 2015, would be $95 or 1 percent of income, whichever is higher. It remains to be seen how punitive the government intends to be, and the decision may depend on the midterm election results, and the number of consumers who prefer the penalty rather than the costs of getting insured.

This spring, the Congressional Budget Office, which is seen as an independent evaluator for legislation and the budget, will update its existing outlook for the health reform law. CBO’s projection that 7 million people (revised to 6 million because of the HealthCare.gov technical stumbles last year) would obtain 2014 coverage shaped expectations heading into Monday’s enrollment deadline.

How do Americans view the law by now?

The public has maintained a generally unfavorable opinion of the Affordable Care Act since its enactment, according to polls since 2010. More than 52 percent of Americans say they oppose the law, while just under 39 percent say they favor it, according to the RealClearPolitics average

Nevertheless, specific provisions are popular, surveys indicate, including parents’ ability to insure their children on their plans through age 26; prescription drugs made more affordable under Medicare; and mandated coverage of pre-existing conditions.

Recent polls find greater support for repairs rather than repeal of the law. A recent Kaiser Family Foundation Health Tracking Poll found 49 percent of Americans support the ACA but would like to see some changes, while 11 percent prefer to replace it with a GOP-sponsored alternative. Ten percent would like to keep the law as is. And 18 percent think Congress should repeal it without any replacement. Independent voters say they favor amending the law (44 percent) over repealing it, adding a replacement (9 percent), or scrapping it altogether (23 percent).

While the administration has for months advertised the law’s March 31 enrollment deadline, and eased the process for employers and applicants, 60 percent of those who say they are uninsured also said they were unaware of the deadline, the Kaiser Foundation found.

What is the GOP political and legislative strategy for Obamacare beyond the deadline?

Since 2011, House Republicans have voted more than 40 times to either repeal or strip away provisions from the law, but are now shifting to "replace" efforts, recognizing public opposition to simply repealing the law and support for some aspects of the program. This altered approach is also part of a broader push to promote the GOP as the "party of alternatives" after efforts to gut or postpone parts of the law led to a partial government shutdown that damaged congressional Republicans' approval ratings. 

Earlier this year, House Majority Leader Eric Cantor said the House would vote on a replacement bill sometime this year. But opening up debate on legislation risks dividing the party in an election year. In the upper chamber, Sens. Richard Burr, Orrin Hatch and Tom Coburn recently introduced the Patient Choice, Affordability, Responsibility, and Empowerment Act and billed it as the GOP’s Obamacare alternative.

Republican candidates say they intend to continue the assault on Obamacare, especially in the wake of the botched rollout last fall and the GOP’s recent victory in a special election in Florida’s 13th Congressional District. Republicans believe their candidate, David Jolly, defeated Democrat Alex Sink primarily because he opposed the health law, particularly federal cuts affecting seniors’ privately purchased Medicare Advantage plans. Jolly’s appeal to seniors, who turn out to vote in significant numbers in midterm elections, also gave Democrats second thoughts about championing ACA changes in their political messaging.

House Speaker John Boehner celebrated the two-point outcome in the Florida race, which many analysts had predicted would go to Sink, and suggested that the GOP should sharpen its focus on the economic effects of the ACA. Republicans “need to stay focused on what the American people are focused on, and that's jobs and the economy,” he said, “but don't underestimate the amount of impact that Obamacare is having on the job market."

Cantor said the House will vote on legislation to recast the ACA’s definition of a full-time employee, as a way for Republicans to underscore their argument that the health law is so onerous it encourages employers to reduce workers’ hours.

On the political front, Republicans accuse Obama of enforcing elements of the law on his own say-so -- a political argument aimed at the president’s sagging job approval numbers and voter mistrust of government. They argue the administration has granted waivers and shifted statutory deadlines to ease Democrats’ political difficulties in light of the serious implementation problems.

Cantor accused the administration of using the latest grace period beyond the March 31 deadline as a way to stall enrollment accounting. “It’s about time the president and Secretary Sebelius release the full and accurate enrollment data they have access to so Americans can truly judge the effectiveness of Obamacare,” he said.

To respond to the enrollment numbers and the political challenge of removing legal benefits once constituents have paid their first premiums, some Republican leaders are questioning the administration's numbers, and the lack of details about the enrollees. "I think they're cooking the books on this. People want to know the answer to that," Sen. John Barrasso said on “Fox News Sunday.”

Are Democratic candidates defending the ACA?

At a press conference last week to describe his party’s legislative agenda, Senate Majority Leader Harry Reid fielded more questions about the potential problems for Democratic candidates created by the law than about the caucus’ economic agenda. Reid and other leaders argue that Republicans tried and failed in 2012 to wield Obamacare as a weapon to defeat Democrats.

Increasingly however, Democratic candidates say they fear that sour public appraisals of the now-implemented law may unite and mobilize Republican voters to turn out in November, especially as the intensity of interest and enthusiasm among Democratic voters has cooled this year.

In a recent op-ed, a half-dozen Democratic senators (three of whom are seeking re-election this year in Louisiana, Alaska and Virginia, respectively) said they wanted to modify the ACA. Sens. Heidi Heitkamp, Mary Landrieu, Mark Begich, Mark Warner, Angus King and Joe Manchin said they would like to let states sell health insurance across state borders; reduce premiums by funding “consumer-driven health insurance cooperatives”; extend health care tax credits for small businesses; add a new tier of coverage with a higher deductible to the menu of options on the federal exchange; and expand ways for consumers to enroll in coverage.

Congressional Democrats say the "keep, but fix" message resonates with voters, given its public support. Democratic pollster Celinda Lake advised candidates against defending the law as is. “In terms of Obamacare, don’t defend it, say it was flawed from the beginning, and we’re going to fix it,” Lake told reporters last week. 

Meanwhile, another group of senators used social media to promote the law’s benefits, especially to young people and women. Connecticut’s Chris Murphy, a freshman lawmaker not up for re-election, last week used Twitter’s popular “throwback Thursday” hashtag to tout examples of Obamacare successes. “#TBT to before the ACA when women paid over $1b more than men a year for coverage,” read one Murphy message. Other Democrats used the hashtag “#ACAworks.”

Alexis Simendinger covers the White House for RealClearPolitics. She can be reached at asimendinger@realclearpolitics.com. Caitlin Huey-Burns is a reporter for RealClearPolitics. She can be reached at chueyburns@realclearpolitics.com.

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