Yesterday, the Affordable Care Act's enrollment deadline was extended once again. The announcement was met with much exasperation from the health-care reform law's loudest critics. In his characteristic terseness, Boehner told the press, "What the hell is this? A joke?" Republican National Committee chair Reince Priebus said, “Another day, another Obamacare delay."
The extension isn't that surprising, given past government rollouts of legislation this vast in scope -- and the Affordable Care Act's own history of deadline fudging. The increasing frequency of extensions also shows that the Obama administration learned an important lesson from Healthcare.gov's debut: "Slow and steady wins the race" is a better adage for them than “Better three hours too soon than a minute too late.” Here's a history of Obamacare's generous extension policy and how everyone reacted.
Nov. 15, 2012: The original deadline for states to decide whether they wanted to set up their own insurance exchange -- and receive lots of federal funding to help them do it -- was Nov. 16, 2012. The day before, however, the Obama administration extended it until Dec. 14. Health and Human Services Secretary Kathleen Sebelius announced the extension in a letter to the Republican Governors Association, which was addressed to Virginia Gov. Bob McDonnell and Louisiana Gov. Bobby Jindal. Sebelius wrote, "We are committed to providing states with the flexibility, resources and time they need to deliver the benefits of the health care law to the American people. We will continue to work directly with individual states to address their particular questions and concerns." The letter was in response to many questions Republican governors had asked about the state-run exchanges and the Medicaid expansion in previous months. In July 2012, McDonnell sent a letter to Sebelius stating, "While we continue to believe the best option is to fully repeal and replace the PPACA, states now confront numerous deadlines and face major policy decisions in the wake of the Supreme Court decision. Before making any final policy decisions, governors must carefully consider the short and long-term implications of an expanded entitlement program and the consequences of significantly increasing the size of government to manage these programs."
Despite the extension, no more states decided to build their own exchange.
July 2, 2013: Last summer, the Obama administration delayed the implementation of the employer mandate by one year, to 2015. The mandate stipulates that businesses with more than 50 employees must provide health insurance or face a penalty of up to $2,000 per worker. Employers had been complaining about the initial time frame for months, and many stories on the delay mentioned how the change eliminated any judgment of the provision until after the 2014 midterms. Many health policy academics thought this was a bad idea. “I am utterly astounded,” Sara Rosenbaum, a professor of health law and policy at George Washington University told the New York Times. “It boggles the mind. This step could significantly reduce the number of uninsured people who will gain coverage in 2014.”
Senior White House advisor Valerie Jarrett wrote a blog post defending the delay: “This allows employers the time to test the new reporting systems and make any necessary adaptations to their health benefits while staying the course toward making health coverage more affordable and accessible for their workers."
It's unclear how many people the employer mandate would affect anyway. The Treasury Department estimates that 96 percent of businesses in the United States have fewer than 50 employees. Many of those with more employees already provide health insurance for their employees.
Sept. 24, 2013: The federal government announced that Healthcare.gov would not be able to transfer Medicaid applications to states immediately when the site opened for business on Oct. 1. Many of the Web site's delays and problems cycle back to the fact that the Obama administration did not expect so many states to reject federal funds to build their own exchanges. Health and Human Services ended up running the insurance exchange for 36 states — a task that required much more manpower than they had originally planned for.
Sept. 26, 2013: The Obama administration announced that Healthcare.gov would not be ready to accept small business insurance applications when it launched the following week. The debut of the Spanish-language version of the Web site, CuidadoDeSalud.gov, was delayed to mid-October.
Oct. 23, 2013: After the messy unveiling of the federal insurance exchange Web site -- and the equally inelegant rollout of many state-run exchange Web sites -- the Obama administration decided to get rid of the confusing separate deadlines it had for the individual mandate. Now, as long as people looking to buy health insurance through the exchanges paid for it by March 31, they would not face a fine. Originally, people would need to buy an insurance plan before Feb. 15 to avoid a fine.
Nov. 14, 2013: The Department of Health and Human Services decides to let state insurance commissioners decide to continue cancelled policies if they fulfill certain conditions, and are renewed in policy years starting between Jan. 1, 2014 and Oct. 1, 2014. The letter to insurance commissioners states, "We will consider the impact of this transitional policy in assessing whether to extend it beyond the specified timeframe."
Nov. 22, 2013: Health and Human Services decided to move the second round of enrollment for health insurance exchanges from Oct. 15, 2014 to Dec. 7, 2014, to Nov. 15, 2014 to Jan. 15, 2015, extending the sign-up period by a week. The new 2015 enrollment schedule completely also erases the sign-up period from election season, which will be done before consumers are allowed to revisit Healthcare.gov. That means that insurance shoppers won't see potential premium prices until after they vote.
Nov. 22, 2013: The Obama administration decided to push back the open enrollment deadline to Dec. 23 for people who want coverage to start on Jan. 1, 2014. The previous deadline was Dec. 15.
Nov. 27, 2013: With all the work necessary to fix the individual insurance marketplace tech, Health and Human Services decided to delay the Small Business Health Options Program — or the SHOP exchange — until November 2014. Small businesses will have to rely on paper applications or insurance brokers until then.
Dec. 12, 2013: Health and Human Services advises insurers to provide “retroactive coverage for people who sign up after Jan. 1," and to offer insurance for people who pay partial premiums. Government-run high-risk insurance plans — which were first implemented in 2010 for people with pre-existing conditions — are also extended for a month. They were originally supposed to expire on Jan. 1 when Obamacare was meant to be unveiled in full.
Dec. 19, 2013: Get one of those cancellation letters from your insurance company? The Obama administration decided to let you keep your plan through 2014 — even though it doesn't meet the minimum standard of coverage the Affordable Care Act requires. Instead, these people, approximately 500,000, will qualify for a "hardship exemption."
After the "if you like your plan, you can keep your plan" debacle the White House faced, it seemed this was their most politically expedient move. A group of senators — some of whom are facing difficult re-elections this year — sent a letter to the White House asking for the delay.
However, this change also makes it harder for the health-care exchanges to keep premiums low.
Asked about the reason for the extra day — and why it was kept secret at first — officials at the Centers for Medicare and Medicaid Services, the federal agency overseeing the health insurance exchange, at first declined to respond and then issued two statements with slightly differing explanations. Julie Bataille, director of CMS’s office of communications said in the second statement that the official deadline for signing up for Jan. 1 coverage remained Monday, but added: “[W]e have taken steps to make sure that those who tried to enroll today but had delays due to high traffic have a fail-safe.”
Jan. 14, 2014: Government-run high-risk insurance plans are extended once again. People in these plans can keep them until March 15, after which they need to sign-up with the Obamacare insurance exchanges.
Feb. 10, 2014: The employer mandate, first delayed in July, is pushed back again — and modified a bit. Now businesses with 50-99 employees have until 2016 to provide their employees with health insurance. For companies with over 100 employees, they still have to offer insurance in 2015 — but only to 70 percent of their full-time employees. Sarah Kliff asked at the time how much getting rid of the employer mandate completely would affect coverage. It turns out, not a lot. But, the government would lose a lot of revenue from companies that decided to pay fines instead of offering insurance.
March 5, 2014: If you like your old plan, you can keep it, at least until 2016. The Obama administration permits state insurance commissioners to delay the timeline at which old insurance plans not up to the Affordable Care Act's standards will be terminated. Again. Previously, the cancelled plans — one of the biggest political fallouts of the Obamacare rollout — were extended until the end of 2014. However, about half of the state insurance commissioners decided not to renew cancelled plans, worried that keeping all of those people out of the insurance exchanges would drive up premium costs. Small businesses are also allowed to renew the old plans. The Congressional Budget Office thinks about 1.5 million businesses kept their to-be-cancelled coverage.
The 2015 open enrollment period is also extended again, by one month. It will now run from Nov. 15, 2014 to Feb 15. 2015.
March 14, 2014: The government-run high-risk insurance plans are extended for the third time. Now people have until April 15 to sign up in the individual insurance exchanges.
March 25, 2014: And now, this week. Health and Human Services had previously stated that this was one deadline they would remain firm on. But, with fears of a repeat of Oct. 1, 2013 high, what with expectations high that a swarm of procrastinators will descend upon the site as the deadline approaches, rendering sign-ups impossible for all, they decided to give people who already started an application a yet-to-be-finalized amount of wiggle room to complete the process in April. Amy Goldstein interviewed the former director of Massachusetts' insurance exchange — the first in the U.S. — about the delay: “The whole point of the thing is to get people covered. In the first year, there has been so much confusion, I think it’s only natural there will be people who just don’t feel as if they fully understood what the law was and what they were supposed to do and that the opportunity would close.” Also, as The Wire points out, "Insurance companies expected this and are waiting to see what the full plan is, and the precedent for special enrollment periods is well established." Given this, the White House would have been best served to look at their history of delays and realize promising punctuality was not a smart move.
It's important to note that the Affordable Care Act isn't the only nationwide health-care policy to face some setbacks in its first year. When Medicaid was first rolled out in 1966, it faced many, many delays and started much controversy. The implementation of Medicare Part D in 2006 featured the same pitfalls that plagued the Affordable Care Act nearly a decade later.
Whether the future will look back and see this list as a history of necessary fine-tuning of a complex law, or an explanation of why the Affordable Care Act was doomed not to succeed, we'll have to wait to find out. For now, however, the list isn't good publicity for a policy people didn't quite understand in the first place, and has only gotten more complicated since.
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