March 23 marks the Affordable Care Act's fourth anniversary, and March 31 marks the deadline for people to sign up for health insurance before fines kick in. That means that people are going to be talking quite a bit about the health care law and how its implementation is going.
The Kaiser Family Foundation has released information about how many people have enrolled in health-care exchanges in each state through March 1. Where people are signing up — and where people aren't — tend to follow an easy political rubric. Out of the entire population eligible to join the health-care exchanges, 15 percent have already signed up, a number likely depressed by the Affordable Care Act's inelegant Internet debut. In conservative states where the exchanges are run by the federal government — 27 in all — only 12 percent of the eligible population has signed up. In the 17 states that built their own exchanges, 20 percent of eligible people signed up. Even when you break down the state-based exchanges by party, the percentage of the population remains the same. Why are these exchanges signing up more people? Because the health-care law was set up to incentivize states to build their own marketplace by providing additional federal funds to help implement the program.
With more money available to publicize the new health-care insurance program and help people sign up, of course these states are doing better on whole. But, things aren't going smoothly in all the states that are running things on their own. And some of federally facilitated exchanges have had great success in signing up people. In some states where Obamacare has incredibly low approval ratings, people are signing up in extraordinary numbers. In some states where the health-care law is popular, sign-ups are nonexistent.
Here's a look at a few states that show how complicated analyzing Obamacare's success can be this early in the game. The law definitely hasn't performed to initial expectations so far, but there's no doubt it's also found success in unanticipated places.
Massachusetts, Maryland, Hawaii and Oregon
These are states where everyone assumed things would work. They're Democratic states with leaders who wanted the Affordable Care Act's rollout to go smoothly. And then their Web sites just wouldn't work. The woes of these states have dovetailed with those of the federal government's exchange – and in many cases have lasted much, much longer.
Hawaii has had the fewest number of sign-ups in the whole nation — 4,661 — mostly due to extended technical problems and little interest from small businesses. Because so few people are enrolled, the state isn't sure it will be able to pay for the exchange when the hundreds of millions of federal dollars run out in 2016.
Maryland has only signed up 9.1 percent of their eligible exchangers, and has hired 200 additional people to work the phone lines because the Web site still doesn't work quite right. The phone lines are always busy, and the wait has frustrated many potential customers. They fired the contractor that built their Web site in late February, and might end up scrapping the site completely.
Massachusetts' Web site is also not working well, and is unlikely to be fixed by March 31. The state has the smallest percentage of sign-ups in the country.
Wonkblog called Oregon's Web site the "nation's worst Obamacare site" yesterday. They just completed a $228,000 review of their technology, and are trying to figure out what to do next. Joining the federally-run HealthCare.gov is an option.
There are many state-run exchanges that have been far more successful. California and New York — which have two of the largest uninsured populations — have together signed up over 1.1 million people. Idaho has the fifth highest percentage of sign-ups by eligible population, although only 36 percent of its residents have a favorable opinion of Obamacare. The state has held over 100 meetings and sign-up events. Vermont, which has a state-based exchange, has signed up 54 percent of its population.
The conservative state government of North Carolina decided not to build a state-run exchange — which would usually mean a small number of sign-ups, if you were to look at most of the states that followed the same course. But North Carolina, Maine and Florida have managed to sign up a significant number of people — when adjusting for the across- the-board decreased standards following the messy November rollout — despite the fact the state government hasn't been as aggressive in pushing sign-ups as states running their own exchanges. In North Carolina and Florida, the number of sign-ups looks promising to the Obama administration since they are two of the ten states with the highest number of uninsured residents. If the Obama administration's last-minute advertising blitz in these states — which also include California, Texas, New York, Georgia, Illinois, Ohio, Pennsylvania and New Jersey — they will get the national tally of sign-ups to go up considerably, too. And that national number is the one everyone will be looking at to give the Affordable Care Act the first semester grades that will define it for November elections.
Texas — where one in four people are uninsured — is likely a lost cause for sign-ups in the near future. The state passed laws this January that makes it difficult to become a navigator, the people who walk enrolees through the complicated sign-up process. Only 39 percent of Texas residents have a favorable opinion of Obamacare. Conservative candidates who have been all over television commercials the past few months have focused much of their attention on the law.
In North Carolina, Obamacare has a 38 percent approval rating. The state has managed to sign up twice as much of its uninsured population for health care — enough to make them surpass their target number of enrollees. What's the difference? Many groups in North Carolina have been aggressive about hosting events and getting people to sign up. Get Covered America has been there since the middle of 2013, and the Council on Aging has held over 20 events in the past two weeks alone.
Maine, which also uses HealthCare.gov, has had 20.8 percent of their uninsured residents sign up for Obamacare, and has surpassed their target. A nonprofit, Maine Health Access Foundation, has spent $2 million on education and sign-up efforts. Western Maine Community Action, Fishing Partnership Support Services and the Maine Lobstermen’s Association have also led big education pushes. The state House of Representatives has also passed a bill to expand Medicaid, but it is unlikely to survive a veto from Republican Gov. Paul LePage
In Kentucky, only 32 percent of residents approve of the Affordable Care Act, but the state has also been a successful model for how to educate residents about their insurance options and get people to sign-up. Approximately 18.2 percent of uninsured residents in Kentucky have signed up so far. Kansas, which has a similar number of uninsured people and similar approval rating for Obamacare, has only signed up 9.8 percent of its eligible enrollees so far.
Kentucky has been getting national attention as a place that was trying to make Affordable Care Act work for awhile. The state's governor, Steve Beshear, is a Democrat, and mostly responsible for Kentucky's adoption of a state-based exchange and the Medicaid expansion, made optional by the Supreme Court's decision on the Affordable Care Act in June 2012. Republican lawmakers in the state were not pleased with either move, and now seek to limit the executive power a Kentucky governor can wield. Jennifer Tolbert at the Kaiser Family Foundation told the Lexington Herald-Leader in February, "Some of the states we thought were leader states have really run into some significant problems. I think the general sense is that Kentucky has done a really good job of identifying people and getting them enrolled."
Though Web site troubles have gotten attention nationally, the level a state has invested in education and in-person sign-ups seems to be one of the greatest determinants of success for many states.
Gov. Rick Snyder was in favor of setting up a state-based health-care exchange in Michigan, but couldn't without the approval of the legislature — which he didn't have. He then tried to set up a joint federal-state partnership exchange in the state — which has voted for the Democratic presidential candidate since 1992. He also couldn't get legislative approval for that, and the state lost all chances for federal funding. The state did approve the Medicaid expansion, however, again proving that Obamacare politics don't always refract along party lines.
The state has also been successful in sign-ups, having the eighth highest number of sign-ups by percentage of eligible population. Republican legislators in the state and outside groups like Americans for Prosperity have continued to campaign against the law.
Who knows how these successes and slip-ups will change in the next years, but it's important to note that there's no one story to tell about the Obamacare rollout, as we learn more data about premiums and sign-ups and Medicaid enrollment in the upcoming months. With such a complex law, there's probably no way we'll know what to make of Obamacare by November. The only thing we have for sure is a crash course in what's working in some states, and what's bombing in others, regardless of whether people like what's happening or not. With such a confusing portrait, it's especially easy for politicians to spin the law every which way. This election, you're going to hear a million different things about Obamacare, and as the above snapshots show, about half of them could even be right.
Scott Clement contributed to this post.
"The Hillary Clinton-Industrial Complex" — Alex Seitz-Wald, National Journal
"Koch Group, Spending Freely, Hones Attack on Government" — Carl Hulse and Ashley Parker, The New York Times
"City vs. Country: How Where We Live Deepens the Nation's Political Divide" — Lauren Meckler and Dante Chinni, The Wall Street Journal