CREDIT: Jessica Rinaldi/Reuters
Next week, as uninsured Americans begin signing up for coverage in the Affordable Care Act’s health care marketplaces, Republicans will seize on the trickle of early beneficiaries and technical glitches to paint the measure as a failure. But administration officials tasked with implementing President Obama’s signature domestic policy accomplishment are anticipating these attacks and are confident they will win the public debate and meet their enrollment targets over the long term.
On Tuesday, the nation’s 48 million uninsured will be able to log on to Healthcare.gov, dial a federal hotline, or visit a community “navigator” and begin enrolling in health care coverage through the law’s state-based exchanges to receive coverage next year. The Congressional Budget Office estimates that 7 million enrollees will participate in the marketplaces in 2014; 9 million will sign up for Medicaid. By 2023, the exchanges will hold 24 million people and the law’s Medicaid expansion will accompany another 13 million.
But health care experts caution that enrollment may prove to be more of a marathon than a sprint and will work best in states that are actively helping uninsured people sign up for coverage.
“It just takes time,” Stan Dorn, a Senior Fellow at the Urban Institute’s Health Policy Center, says, pointing to the nation’s experience in encouraging people to sing up for the Children’s Health Insurance Program, a bipartisan Clinton-era initiative that primarily provides health insurance to children in families with incomes too high to qualify for Medicaid. Enacted into law in August of 1997, the plan began enrolling children in 1998, but initially fell short of enrollment goals. Four years later, the Congressional Research Service issued a disappointing report noting that just 60 percent of eligible kids were enrolled in the program. Today, 87 percent of eligible children have coverage in CHIP or Medicaid.
“It’s like any other human activity, it takes time to figure out how to do it right,” Dorn remarks. “I think it’s far more realistic to expect [from Obamacare] what we saw with CHIP, which is a 5 to 6 year ramp-up and that’s in the states that want the program to work,” he explains. “In the states that are fighting tooth and nail, it will be a much slower trajectory.”
To meet enrollment targets, the federal government and its state partners will have to build what Dorn describes as a three-legged stool: grow public awareness about the law and what’s in it, perfect and simplify enrollment procedures, and ensure that uninsured families have help in applying for coverage. A certain percentage of the uninsured who are eager to take advantage of health care benefits will sign up for coverage in the early days of open enrollment, while the majority will likely wait until immediately before the enrollment period closes at the end of March.
That’s what happened in Medicare Part D, President George W. Bush’s program extending prescription drug coverage to the Medicare population. More than half of the beneficiaries who ended up signing up for insurance didn’t do so until after the first of the year and enrolled despite the Bush administration’s well-publicized initial glitches in extending coverage to low-income beneficiaries. Whereas only 21 percent of seniors had a favorable impression of the law and 66 percent didn’t know what was in it in April of 2005, by November of 2006, “half of the seniors polled said the program was working well or that just minor changes were needed.”
The experience isn’t exactly analogous to the Affordable Care Act, a new stand-alone program that will have to reach individuals who are not already connected to the health care system and may be jaded by GOP efforts to dissuade them from obtaining coverage, but it does include lessons for federal and state officials implementing reform.
“Go in with an expectation that there will be glitches,” says Jack Hoadley, a Research Professor at Georgetown University’s Health Policy Institute who co-wrote a report examining what lessons Part D holds for the new health insurance marketplaces. But “if you’re prepared for that possibility you can go in and fix most if not all of the glitches, soften the ones that you can’t completely fix, and get passed them and move on.”
Administration officials say they’ve learned from the Bush administration’s failures. “It’s no accident that there is a 6-month open enrollment period – that is because of the experience of everyone looking back and saying one month was too short,” a senior administration official explains. “We also have the obvious lessons of Part D, trying to make sure we have communication with people…we train our trainers… making sure we have partners who are trusted partners in communities who know how the law works is critical because in Part D there was a lot of concern about whether or not some of the local advocates really understood the law and we worked very hard in trying to address that this time around.”
“We’re not saying we fail if we don’t get one of these [target enrollment] numbers, we’re really just trying to take this as, you know, recognize that we need to ramp up.”