Healthcare reform should be the signature Democratic achievement of President Barack Obama’s presidency. But with "Obamacare" five months from show time, Democrats are worried about whether enough Americans will sign up to make the sweeping healthcare overhaul a success – and what failure might mean for Congress heading into the 2016 presidential race.
Some of the law’s main advocates fear that not enough of America’s 49 million uninsured will know about health coverage offered in their own states. Even if they do, new insurance plans may not be attractive to young, healthy consumers needed to offset an expected influx of older and sicker patients.
Only a handful of states are beginning campaigns to promote the online health insurance marketplaces created by the law. Known as exchanges, the markets will offer private coverage at federally subsidized rates to individuals and families with low-to-moderate incomes, with enrollment set to begin October 1.
The federal government has kept quiet about its promotion plans, which are expected to begin in earnest over the summer. While Obama and his administration say they are working nonstop on reform, analysts believe a poor performance could make the Patient Protection and Affordable Care Act a big enough campaign issue in 2014 to jeopardize Democratic control of the Senate – particularly if insurance costs rise sharply.
"There is reason to be very concerned about what’s going to happen with young people. If their (insurance) premiums shoot up, I can tell you, that is going to wash into the United States Senate in a hurry," said Senator Ron Wyden, an Oregon Democrat.
Some Democrats are frustrated about the lack of details surrounding administration plans to promote the exchanges. Senator Max Baucus, a chief architect of the reform law, said federal outreach efforts deserve a failing grade so far and could be heading for a "huge train wreck." He criticized Health and Human Services Secretary Kathleen Sebelius for the scant information her department has provided.
"Why in late April can’t they show us any of what they’ve got planned? The rollout plan should already be in existence," an exasperated Democratic Senate aide said separately. The law is expected to cover 15 million Americans next year through the exchanges and an expansion of Medicaid. The overall number is forecast to jump to 38 million by 2022.
Reform is facing challenges on several fronts. Big insurers appear wary of participating, raising questions about how competitive the exchanges will be. Businesses are mounting a new legal effort to stop the use of federal subsidies in exchanges run by Washington. And most states have balked at the exchanges and the Medicaid expansion.
Meanwhile, the enrollment effort is under threat from months of delay, a congressional Republican embargo on new funding and worries about how affordable the new plans will be, according to analysts, lawmakers, congressional aides and former officials.
"I don’t see how what they’re planning to do is going to be adequate. The resources are too limited, the (law’s) penalties are too weak and elite opposition in much of the country will undermine" enrollment, said Paul Starr, a Princeton professor and former health adviser to President Bill Clinton.
Add to that the challenge of reaching a public that is highly skeptical and often misinformed about the most complex social legislation since Medicare and Medicaid in the mid-1960s.
A Kaiser Family Foundation poll found that 77 percent of Americans know little or nothing about exchanges, while 40 percent erroneously think reforms create a government panel to make end-of-life decisions for people on Medicare.
An April survey of 1,003 people by HealthPocket, an online company that helps consumers find insurance, also found that the law’s penalty for not buying coverage would not induce most 25-to-34-year-olds or 18-to-24-year-olds to purchase it.
GLITCHES AND BUMPS
Obama this week defended the pace of implementation, telling reporters that the government was working hard to "make sure that we’re hitting all the deadlines and the benchmarks" even with the challenge of building the new online exchanges.
"That’s still a big, complicated piece of business," Obama said, adding the task was made harder by a dedicated Republican opposition still determined to block the law’s implementation. "Even if we do everything perfectly, there’ll still be, you know, glitches and bumps," he said.
The administration is building exchanges in 33 states that are unwilling or unable to do so on their own, and has limited funds for marketing. The remaining 17 states are building their own and have received sizable budgets for outreach.
Among states taking the lead, Vermont has launched radio advertising to raise public awareness. Colorado begins its public outreach this month, while California, Maryland and the District of Columbia will hold off until later in the year.
For the federal exchanges, HHS has a contract worth at least $8 million with public relations firm Weber Shandwick and $54 million to train and pay "navigators," or counselors who will help consumers choose a health plan. It also has a $28 million contract with General Dynamics to set up a call center and will make its Healthcare.gov website consumer-oriented.
The administration is seeking help from major U.S. insurance providers to market aggressively to consumers on the federally run exchanges and help convince healthy citizens between 26 to 45 to pay for insurance instead of a first-year penalty amounting to $95 per person or 1 percent of household income.
But reform advocates worry that the HHS budget is too small and the spigot for new funding from Congress is shut off by partisan politics. The "navigator" program allocates just $600,000 each for 13 states including Delaware, Iowa, Kansas and New Hampshire.
"There’s a limited amount of money that should be increased. But that’s subject to appropriations and Congress is not likely to appropriate additional money," said Ron Pollack of the advocacy group Families USA. "It’s going to require a very robust effort in the private sector."
Analysts say reform could be as big an issue in next year’s congressional midterm elections as it was in 2010, when dislike for the law among senior citizens helped install a Republican majority in the House of Representatives. This time, failed implementation could end Democratic hopes of recapturing the House and leave enough Senate Democrats vulnerable to give Republicans an edge in that chamber.
"We have to see how bad it is. This issue blowing up on Democrats would make the Republicans’ job a lot easier," said Jennifer Duffy of the Cook Political Report.
But Democrats believe implementation will also provide favorable coverage of deserving individuals and families finally being able to secure adequate and affordable health coverage after a long sojourn through the current marketplace.
There has been encouraging news for consumers. Vermont says 2014 premium rates will save money for residents. A family of four with an annual income of $75,000 would pay less than $600 per month for coverage with a federal subsidy, versus $900 for the cheapest small group plan available today.
Additional reporting by Sharon Begley and Caroline Humer in New York