Obamacare starts in 99 days. These 99 things need to happen before then.

June 24, 2013

Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, and read previous columns here.

Obamacare hit a pretty important milestone this weekend: The law is now 100 days away from its main provisions coming into effect. That means the administration is pretty much in an all-out sprint to set up an infrastructure by which millions of Americans will soon purchase insurance coverage.


A potential approximation of an Obamacare summer to-do list? (Jahi Chikwendiu/The Washington Post)

It's hard to understate the enormity of the task at hand for the Obama administration. It will be orchestrating the largest expansion of private health insurance in the country's history. That means there's a huge amount of work to be done over the next few months. There are at least 99 things that need to happen between now and October, and I've got a list to prove it. Much of this is informed by the Government Accountability Office report that came out last week, on the next big steps that need to happen on health exchanges. Some are big, some are small but all are pretty necessary to making the law work.

Here they are:

1. Health and Human Services must certify that 17 states will be able to launch their own marketplaces. While these states currently have conditional approval, none have the final go ahead to launch their exchange.

That means that...

2. Washington State must launch a health insurance exchange

3. Oregon must launch a health insurance exchange

4. California must launch a health insurance exchange

5. Idaho must launch a health insurance exchange

6. Hawaii must launch a health insurance exchange

7. Colorado must launch a health insurance exchange

8. Minnesota must launch a health insurance exchange

9. Kentucky must launch a health insurance exchange

10. Exchange list interruption: The federal government likely needs to work on the fact that 42 percent of Americans don’t know that the health-care law is a law at all.


11. New York must launch a health insurance exchange

12. Vermont must launch a health insurance exchange.

13. Massachusetts must launch a health insurance exchange.

14. Connecticut must launch a health insurance exchange.

15. Rhode Island must launch a health insurance exchange.

16. The District of Columbia must launch a health insurance exchange.


Picture break! (Marc-Antoine Baudoux / AFP/Getty Images)

17. Maryland must launch a health insurance exchange.

18. Utah must launch a small-business health insurance exchange.


The Obama administration can only hope its state-federal partnership exchanges go as smoothly as this goat-horse partnership (YouTube)

19. There are another six states where the federal government will need to partner with the state to run a health exchange.

20. HHS will need to partner with Iowa to build a health insurance exchange.

21. HHS will need to partner with Arkansas to build a health insurance exchange.

22. HHS will need to partner with Illinois to build a health insurance exchange.

23. HHS will need to partner with West Virginia to build a health insurance exchange.

24. HHS will need to partner with Michigan to build a health insurance exchange.


25. Exchange list interruption, continued: 43 percent of Americans currently view the Affordable Care Act unfavorably. That’s another challenge you can bet the administration is currently working on.

26. HHS will need to partner with New Hampshire to build a health insurance exchange.

27. HHS will need to partner with Delaware to build a health insurance exchange.

28. That leaves a whole bunch of states where the federal government needs to step in, and build a health insurance exchange itself.

29. The federal government must launch an exchange in Alaska

30. The federal government must launch an exchange in Arizona

31. The federal government must launch an individual-market exchange in Utah

32. The federal government must launch an exchange in Montana

33. The federal government must launch an exchange in Wyoming

34. The federal government must launch an exchange in New Mexico

35. The federal government must launch an exchange in North Dakota

36. The federal government must launch an exchange in South Dakota


President Washington wonders, are stone statues in South Dakota subject to the individual mandate? (Flickr)

37. The federal government must launch an exchange in Nebraska

38. The federal government must launch an exchange in Kansas

39. The federal government must launch an exchange in Oklahoma

40. The federal government must launch an exchange in Texas

41. The federal government must launch an exchange in Missouri

42. The federal government must launch an exchange in Louisiana

43. The federal government must launch an exchange in Wisconsin


A Wisconsin picture to break up this very long list! (Flickr)

44. The federal government must launch an exchange in Tennessee

45. The federal government must launch an exchange in Mississippi

46. The federal government must launch an exchange in Ohio

47. The federal government must launch an exchange in Alabama

48. The federal government must launch an exchange in Georgia

49. The federal government must launch an exchange in Florida

50. The federal government must launch an exchange in South Carolina

51. The federal government must launch an exchange in North Carolina

52. The federal government must launch an exchange in Virginia

53. The federal government must launch an exchange in Pennsylvania

54. The federal government must launch an exchange in New Jersey

55. The federal government must launch an exchange in Maine

56. HHS must work with each of these states to create a "mitigation strategy," according to a recent GAO report, that will "ensure that all applicable exchange functions are operating in each state on Oct. 1, 2013.

57. If a state cannot handle the responsibilities of running a health insurance exchange, the federal government will need to step in and take over the task itself. This has already happened in Michigan and New Mexico.


New Mexico: Land of enchantment, if not a locally run health exchange (Flickr)

58. The federal government must sign contracts with at least two multi-state plans, which will sell in at least two-thirds of the states in 2014.

59. Massive call centers must open, big enough to handle 42 million calls by the end of this year.

60. All those call center agents will need to undergo training on the Affordable Care Act. This is important: When Part D launched, about one-third of seniors got an inaccurate or incomplete answer from the new call center.

61. You can bet there will be lots of calls: As of November, the vast majority of Americans expected to be eligible for benefits had no idea that they would become available.

62. The Center for Medicare and Medicare Services must complete testing of complex technology systems “to determine eligibility for enrollment into a qualified health plan,” according to the GAO. This is scheduled to finish in September.

63. The GAO says that the Medicare still needs to establish “business service definitions” for the federal exchange. Those “describe the activities, data elements, message formats and other technical requirements that must be met.”

64. Another technical milestone to be met, again from the GAO: Medicare needs to create “computer matching agreements, which establish approval for data exchanges between various agencies systems”

65. And a third from the GAO! This one is about data use agreements that still need to be made and “establish the legal and program authority that governs the conditions, safeguards and procedures under which federal or state agencies agree to use data.”

66. Medicare needs to evaluate hundreds of bids from health insurance plans to sell on the federally-facilitated exchange.


I'll give you $290 for a health plan! (Sotheby's)

67. By August 26, Medicare plans to give insurance plans a preview of the data that will display on the new health insurance exchanges.

68. By Sept. 15, the GAO says the agency expects “to finalize the qualified health  plan information and load it into the exchange website.”

69. Health and Human Services must send out a first round of funding for navigators, who are meant to help with exchange education and outreach, by Aug. 15.

70. The agency then plans to hold a training program for the individuals who do receive navigator awards.

71. By Oct. 1, the navigator program must be up and running in the 34 states where the federal government is running the health insurance exchange.

72. The federal government has also promised to fund a navigator in every federally-qualified health center across the country.

73. Health insurance plans are, meanwhile, working up their own outreach campaigns to lure customers to their new health exchange products.

74. By this summer, the federal government plans to translate its educational materials into 25 languages.


Te quiero...Obamacare? (Flickr)

75. Medicare plans to create a complaint tracking system to monitor for problems in the health insurance exchange.

76. Forgot about the small business health exchange? Health and Human Services hasn’t! By July, many states told the GAO that they plan to finish certifying insurers that want to sell on this marketplace.

77. Of the 18 state-based small business exchanges, 10 plan to start call center training in July or August.

78. Seventeen of those 18 states plan to have their agents and brokers doing outreach work beginning this month.

79. “Most remaining eligibility and enrollment key activities [for the SHOP exchange] were targeted to be completed by states by July 31,” according to the GAO.

80. Medicare needs to finalize a single, streamlined application that Americans can use to apply for both Medicaid and tax subsidies. Speaking of Medicaid...

81. States must prepare to expand Medicaid to all people with an income lower than 133 percent of the federal poverty line.

82. States need to change how they count income for Medicaid, using tax data rather than some of the asset tests and income disregards sometimes used by the public insurance program.

83. Thirty-six Mississippi counties must wait to find out whether they’ll have any options available on their health exchange come October.

84. Mississippi also needs to figure out whether it will have a Medicaid program at all come October. Fun times!

85. The federal government must decide whether to approve Arkansas’s Medicaid expansion plan, which would use Medicaid dollars to buy private health insurance plans.

86. Companies need to begin monitoring how many hours their employees work, to know who counts as “full time” and must receive health insurance benefits.

87. The Internal Revenue Service needs to finalize a form where individuals will report their source of health coverage (or, alternatively, report no coverage and potentially pay a fine).

88. Enroll America, a nonprofit focused on maximizing enrollment under the Affordable Care Act, must launch its outreach campaign focused heavily in 10 states.

89. I’m surely forgetting one, right?

90. The administration will apparently continue talks with the National Football League and other professional sports leagues about partnering on outreach efforts.

91. I’m probably forgetting more than one, now that I think about it.

92. Maryland needs to finish approving the rates that health insurers have proposed for its health insurance exchange in 2014.

93. The Maryland Health Benefits Exchange also plans to launch its own outreach campaign in August.

94. The Washington Healthplanfinder needs to open its own call center on Sept. 1.

95. Cover Oregon director Rocky King estimates he has “4,300 things” that need to happen by Oct. 1. Among them: Holding 350 trainings across the state with community partners.

96. California needs to hire and train about 1,000 phone agents to work at three sites across the state.

97. Connect for Health Colorado appears to need to hire a health plan account manager in the not-so-distant future.

98. HHS will send out periodic updates on the marketplace’s progress to those who register on the new HealthCare.Gov.

99. Health and Human Services must implement the most important health law provision of all: A baby otter for each health policy reporter.*

*Not an actual provision of the law but rather a fantasy of this health policy reporter.

KLIFF NOTES: Top health policy reads from around the Web.

A Louisville clinic is trying to adopt the health-care law. "One morning last month, a health clinic next to a scruffy strip mall here had an unlikely visitor: a man in a suit and tie, seeking to bring a dose of M.B.A. order to the operation. A dozen clinic employees, who spend intense, chaotic days treating an unending stream of Louisville’s poor and uninsured, stared stonily at handouts he had brought as he made his pitch." Abby Goodnough in The New York Times.

Blue Cross Blue Shield plans are playing big on the new exchanges. "They’re expected to offer health-exchange plans nearly everywhere, ensuring at least a minimum choice for individuals seeking subsidized coverage when the marketplaces open Oct. 1. It also makes them an undeclared Obama ally in implementing the health law." Jay Hancock in The Washington Post

Will Obamacare lead to...better hospital food? "Rex, part of the University of North Carolina Health System, is one of a growing number of hospitals nationwide that are tossing out their fryers and adopting hotel-style "room service" where patients can order food anytime from a large menu.  Many are also setting up gardens to grow their own vegetables, inviting local farmers to sell produce in their lobbies and turning food presentations into works of art -- even when made puree style." Phil Galewitz in Kaiser Health News.

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