Obamacare Enrollment Crisis

Written By Brian Hicks

Posted July 26, 2013

The great promise of what will arguably go down as President Obama’s signature official act—the Affordable Care Act—was that it would fundamentally transform, for the better, the picture of health care insurance in the country.

Thus, when the state-based insurance exchanges open office in 2014, numerous Americans will receive affordable health insurance for the first time. But there’s a problem.

Patient DoctorIn as many as 21 states where Medicaid is not being expanded, low-income adults are at risk of not being eligible either for coverage under Medicaid or for premium subsidies from the new exchanges, reports CNNMoney. That could mean that in 2016, we may see as many as 4.9 million uninsured people (assuming those states hold fast to their position of not expanding Medicaid). Why are we facing this possibility?

Originally, under the Affordable Care Act, adults with income below 138 percent of the poverty level were to be covered under the provisions of Medicaid. Those earning between 138 percent and 400 percent of the poverty level would receive federal subsidies in order to help them buy insurance from the state exchanges.

The problem arose when a Supreme Court ruling last year stated that it’s up to the state to decide whether to expand Medicaid to accommodate this provision or not. Perhaps predictably, states chose along partisan lines, and here we are—23 states and D.C. have opted to expand Medicaid, and in these places, the ACA will go smoothly into effect as originally planned.

The rest of the states, which includes numerous Southern states and most of the traditionally conservative states, are going to face problems. That’s what could reflect, somewhat undeservedly, on the ACA itself. Consider CNNMoney’s example of Texas to see how this could work out.

Texas already has the highest number of uninsured residents in the U.S. It also has extremely tight Medicaid rules. In order to qualify for Medicaid benefits, you cannot earn more than 25 percent of the federal poverty level if you’re a working parent. And if you’re an unemployed parent, you cannot make more than 12 percent.

If Texas were to expand its Medicaid provisions, an additional 1.5 million would come under the wings of the ACA…but Texas has chosen not to expand, thus making it appear as though ACA disregards as many as 1.5 million.

State Responsibility

There are some other issues that need to be accounted for if the ACA is going to function as intended. For example, the ACA is set to come into law on October 1. Just recently, the federal administration has set forth a guidance—a 600-page tome, in fact—that employers and states must follow in order to determine health care eligibility.

That does sound a bit poorly planned. After all, it’s one thing to cobble together an enormously complex national health care plan. It’s quite another to actually see it implemented as intended on the ground-level.

That’s something that will, ultimately, be up to the actual implementers—the employers and the states. If they can’t enforce the ACA’s provisions efficiently, then no amount of planning can compensate for a failure to launch.

Over at the Washington Post, Jennifer Rubin’s highly partisan piece nonetheless makes a key point in this regard. On the one hand, the setup and administration of the new health care exchanges has been left up to the states. On the other hand, certain states have refused to expand Medicaid in order to accommodate the provisions of the ACA.

Of course, supporters of the ACA would comment that this constitutes a deliberate attempt to cripple the ACA (i.e. by not implementing it as it was engineered to be, it can obviously not work as intended). On the other hand, this is a problem that really ought to have been worked out in the first place so that the Supreme Court would never have had to intervene.

Needless to say, the next few months of ACA coverage are going to be intensely partisan. Witness Fox News, where we learn that 85 percent of Republicans would like the ACA repealed, compared to 72 percent of Democrats who support it. There isn’t likely to be much middle ground here.

We should expect teething problems that could burgeon into larger problems as the ACA comes into effect; it’s unrealistic to expect a massive, nation-wide plan to magically materialize in the face of stiff resistance along partisan lines without any hitches. The real question, however, is whether the ACA can be set in place smoothly enough to tide over the early snags.


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