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.

Days until marketplaces launch: 43. 

Alaska's mountains were largely silent on Obamacare. Cruise ship passengers were another story (Tina Kliff) Alaska's mountains were largely silent on Obamacare. Cruise ship passengers, well, that's another story. (Tina Kliff)


I spent last week on a cruise from Alaska to Seattle. This was my very first cruise and, as such, I learned a number of things. First, cruise ships have an absurd amount of food. Second, I am capable of eating said absurd amount of food. Third, one could launch an excellent Tumblr of cruise passengers sleeping in public with their mouths open.

But, much more relevant to this this article, I learned that, at least on this tiny, floating slice of America (approximate population: 3,000) there was one question about Obamacare that surfaced more frequently than any other: Is the law actually going to work?

I had this conversation with a woman from California, lounging on poolside deck chairs, and a man from St. Louis, who also had questions about whether he would lose access to his doctor.

The conversation would typically start with me mentioning that I cover health policy for the Washington Post, mostly Obamacare. After clarifying that no, I would not soon receive a free Kindle, there would be a question along the lines of "So, is this law going to actually happen/work/succeed?"

Spotted in the Alaska State Senate: Medicaid literature! (Sarah Kliff) Spotted in the Alaska state senate: Medicaid literature! (Sarah Kliff)

This was true, it's worth pointing out, from people who professed to support the law–and those who aggressively opposed Obamacare. There was a pervasive sense, at least among the people I chatted with, of uncertainty about whether this law they'd heard was coming soon would make the health care system better or worse.

And here's the most embarrassing part: I couldn't give them an answer.

Even after writing about Obamacare for four years, I couldn't tell them, when the flip switches on October 1, if the Affordable Care Act would go off without a hitch–or barely function. This would typically elicit a quizzical look, and a bit more of an explanation, one that I've thought through in a bit more detail since stepping off the boat.

This bear, while quite interested in salmon fishing, had no Obamacare queries (Tina Kliff) This bear, while quite interested in salmon fishing, had no Obamacare queries. (Tina Kliff)

We're 43 days out from open enrollment, when Americans can start signing up for the health law's new programs. The Obama administration, which has missed other deadlines, has been adamant about hitting this target. In repeated comments and interviews, Health and Human Services Secretary Kathleen Sebelius has committed to an Oct. 1 launch.

We know that there is tons of outreach work already happening, both at a national and state level. The White House has a very granular plan for targeting their most important population: The young and the healthy. Marketplaces are rolling out advertising campaigns weekly; Enroll America volunteers are going door to door to gather up names of people who likely will qualify for new benefits.

At the same time, the health care law faces significant obstacles. Many states have decided not to support or promote the law, leaving that task to the federal government. Some opponents are launching counter-campaigns, specifically aimed at discouraging people from signing up for the new programs.

Technology testing has fallen behind schedule. Due to those delays, some of the final testing will now happen just hours before the marketplaces open to the public. The Obama administration has been largely tight-lipped about technological readiness, aside from claiming to be, as Deloitte's Cheryl Smith has described it, "freakishly on schedule."

But, as Smith told me a little bit ago, its still hard for outsiders to know what, exactly, this looks like on the inside. “It’s pretty much a black box,” she says.  of the technology that powers the health law. “Only the people who work in this can tell you if it’s actually running on time.”

What makes it difficult to predict Obamacare's success–for me, at least–is understanding how the Obama administration's dedication and the many obstacles it faces ultimately balances out. Moreover, defining success, or what counts as "working," is also a difficult undertaking.

One state that has helped me think through these issues is Oregon, which has aggressively implemented the Affordable Care Act. It was among the first to launch an outreach campaign and has done extensive research into who it needs to reach–and how it will reach them. 






Oregon announced last week that it would delay a pretty significant element of its marketplace: When it launches in October, only certified insurance brokers and "community partners" will be able to use the site. Individuals will not have access on their own; they will have to seek out a broker or partner who can sign them up.

The decision to delay, officials told the Oregonian, was made to avoid overloading the system right when it launches.

It seems plausible to me that, because of the aggressive outreach campaign, lots of people will still sign up for coverage, through these sources, and Oregon's Obamacare experience will be deemed a success. It seems equally likely though, that the change will steer people away from the marketplace and depress coverage, indicating that the law wasn't working as intended.

Which of the two situations will actually play out, or will there be a third, more middle-of-the-road outcome? At this point, I don't know.

Whether on a cruise ship in the Pacific Ocean or a cubicle in Washington, I find predicting the health law's fate incredibly challenging. "I don't know" isn't a very satisfying answer, especially when its about the fate of a major policy initiative that launches in less than six weeks. But, that was my answer on the cruise ship, and the one that I'm sticking with now that I've returned to Washington.

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

Health and Human Services is launching an Obamacare video contest. "The Department of Health and Human Services will debut a video contest -- complete with cash prizes -- designed to persuade younger consumers to get insurance. The administration will partner with Young Invincibles, a non-profit youth issues organization, to run the contest, with the goal of reaching those younger Americans who are skeptical of the need for health coverage." Sam Stein in the Huffington Post. 

Minnesota wants to woo young people into buying health coverage. "'What really appeals to that younger age group is both affordability -- they feel they just can't afford it -- and also communicating the value of insurance and how valuable it is to have that insurance and why you need,' according to April Todd-Malmlov, the executive director of MNsure, Minnesota's online insurance marketplace. Minnesota is one of the 16 states that's building its own exchange. Todd-Malmlov said Minnesota will target young adults in two ways -- in the social media they use, such as Twitter and Facebook, and the messages themselves." Elizabeth Stawicki on Minnesota Public Radio

Sebelius' number one task: Combatting 'misinformation.' "Kathleen Sebelius, the secretary of Health & Human Services, said the Affordable Care Act will succeed in states run by Democrats who have embraced the law. In states such as Georgia where the governor and legislature are in Republican hands, 'the job is made doubly difficult,' Sebelius said in an interview today during a visit to Atlanta to meet with supporters of the law." Alex Wayne for Bloomberg