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A guide to surviving Obamacare debates at Thanksgiving

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 or sign up here to receive it straight from your inbox. Read previous columns here.

Ah, Thanksgiving: That treasured, American holiday where you can eat an incredibly uncomfortable amount of food and have incredibly uncomfortable political conversations, all at the same time!

This Thanksgiving, it's a pretty safe bet that debates over Obamacare will be just about as central as turkey. As Wonkblog readers hit the road and head home, we didn't want to leave you totally unprepared. Here's a guide to the questions you might get -- and their answers.

Your mom wants to know whether Obamacare is a total disaster. 

This is probably the most obvious question to come up on Thursday: How busted is this law? These questions might refer to recent reports that might not be fixed by the end of December or that a third of the computer system still hasn't been built.

It's fair to say the launch of HealthCare.Gov has not exactly gone as the White House would have hoped. Officials promised that Americans would be able to purchase coverage on Oct. 1. That turned out to be true for exactly six people. For many more, it was impossible--and shopping remains difficult even today.

Only a fraction of the people the Obama administration expected to sign up for insurance in October actually bought coverage. If that trend continues, the law won't get anywhere close to its projections that 7 million people will sign up for coverage in 2014.

That's the part of the health-care law that isn't working. But in some states that built their own insurance marketplaces, Obamacare is working--and the health law is meeting enrollment projections. California, for example, has signed up 80,000 people for coverage and Washington has enrolled nearly 12,000. These examples are limited, but the suggest that the problem isn't with demand but a technical one. We won't know whether this is true everywhere, though, until is fixed.

Your father is convinced that Obamacare is a total disaster, and recovery is impossible, because: Death spirals. Young people won't sign up this year, premiums will spike and, by next Thanksgiving, Obamacare is pretty much done for. 

This is a riff on the so-called "death spiral" and it calls to mind something that Kaiser Family Foundation vice president Larry Levitt recently told my colleague Ezra Klein: "You give a little bit of actuarial science to people and they go nuts."

Yes, there would eventually be a "death spiral" if we had an insurance program where only the really sick people signed up for coverage. That would make insurance incredibly expensive and unappealing to young people.

The thing is, the health-care law includes a number of safeguards meant to mitigate the impact of lousy enrollment and make it a bit easier for insurance companies to weather the first few years. These include policies that give extra payments to insurance companies that end up with really sick enrollees  and those who set their premiums too low to cover their costs.

If by some freak accident you happen to be born into a family of actuaries, you can call these risk adjustment and risk corridor payments. If that does not happen to be the case, just describe these as transitional policies that stretch until 2017 and give the health law a bit of breathing room. These policies essentially guarantee that premiums won't spike in 2015--or 2016. They might in 2017 but, before then, we're not looking at imminent failure.

Your grandfather has some concerns about getting death paneled. 

You can reassure any elderly relatives that there is absolutely, definitely, without a doubt no death panel in the Affordable Care Act. There is an Independent Payment Advisory Board, which would be allowed to recommend payment cuts for doctors who serve Medicare patients. This board is not allowed to deny patients' care; they only get to tinker with reimbursement rates.

On top of that, the IPAB isn't going into effect this year--or in the foreseeable future. That's because it only kicks in when health-care costs are growing faster than the rest of the economy, and right now they're growing at about the exact same rate. So, at least until Thanksgiving of next year, there is no chance of any panel changing his benefits.

Your really liberal aunt from San Francisco thinks this would all be working perfectly if we'd just enacted single-payer.

Setting the immense legislative and political hurdles standing in the way of creating a single-payer health care, we do at least have some evidence that building a government-run insurance system isn't exactly an easy lift. Vermont is attempting to do so right now and it's been a bumpy road. Most recently, a new report estimated the state would need $2 billion in new taxes in order to finance its planned health-care system.

Meanwhile, you know how Obamacare canceled a few million policies? Single-payer would presumably cancel every private policy. Imagine the political outcry if rather than a few million cancelled policies, there were tens of millions, or hundreds of millions, as the government moved everyone onto government-provided insurance. Bring that up, and watch the mashed potatoes fly!

Your brother who has insurance at his job wants to know if he needs to pay attention to this slightly uncomfortable fight.

Probably not: We're really not seeing much in the way of employers dropping workers into the marketplaces. He can keep his focus squarely on such important issues as when will Hannukah and Thanksgiving overlap again, or how long he has to stay at the dinner table.

Your uncle who is losing his health insurance plan thinks he'll pay more under Obamacare. Perhaps he brings out his cancellation notice after a few glasses of wine, who knows.

There are about 7 to 12 million people losing insurance coverage under the health-care law this year and, while they make up less than 5 percent of the population, it's not unfathomable that one of them will turn up at your Thanksgiving table.

Your uncle has a right to be angry, given that he got a promise he could keep his plan, if he liked it. But it also turns out there's a chance that he can: The president announced earlier this month that insurers have the option of re-issuing cancelled plans, provided the state insurance commissioners go along with the plan. If he wants to know whether his insurance regulator is on board, he can check this list.

If your uncle does have to get a new insurance plan, chances are it will include more benefits than what he has now, since all compliant plans need to cover 10 essential benefits. But more benefits cost more money, which means his premium might go up. It's possible though, depending on what he earns, he might qualify for a subsidy to purchase that plan. You know what goes great with pumpkin pie? A whirl on the Kaiser Family Foundation subsidy calculator to get an estimated Advance Premium Tax Credit!

Your cousin who supports Obamacare is pretty sure the disastrous roll out is the result of hackers who hate the law.

This is a thread of reasoning that turns up a decent amount in my inbox: Surely the whole screw-up is due to health law opponents who have screwed up the Web site, perhaps by overloading it with traffic.

Most reporting, though, shows that this is not true and even the Obama administration readily admits that it, with a strong assist from government contractors, botched the launch. It also vociferously denies any successful hacking attacks on the Web site, which should be the last nail in the coffin against this argument.

Your cousin's significant other who has a bachelor's degree in computer science thinks if the administration just did [insert thing they should do here], the Web site would be fixed.

Maybe the suggested fix would work, maybe it wouldn't. Either way, there's a decent chance that whatever suggestions come up at the dinner table are unlikely to be the one silver bullet to get up and running. That's because there are lots of problems that range from difficulty sending enrollment forms to health insurance plans to getting subsidy calculations right. Unless your suggested solution includes a way to connect all of the agencies in this diagram, it, sadly, is unlikely to be's magical fix.

Alternatively, if the proposed fix does involve all the agencies above, you should probably get your cousin's significant other on the phone with Jeff Zients immediately.

Your sister who would like to know how to enroll in Obamacare--or when the Web site will work well enough for her to do so.

The best place to start is, which will direct your sister to her state insurance exchange, regardless of whether it is being run locally or out of Washington. Once there, she could get started on the shopping process.

As to the best timing, the federal government has said that the Web site should work smoothly for most users by the end of this month--conveniently two days after Thanksgiving. By "most users," they mean that about 80 percent of shoppers should have a smooth experience purchasing coverage. Thanksgiving evening could actually be a great time to shop, given that the Web site tends to do better when there are fewer users.

That weird guest who you're not sure even knows anybody at Thanksgiving has a pretty weird and specific question.

Who invited this guy to Thanksgiving? Who knows! But chances are if he has a very specific question about the health care law, we've addressed it in this big explainer on life under Obamacare, this one on all the technical glitches or this one on cancellation notices. Good luck with mystery guest!

Health Reform Watch's Fix Tracker! 

President Obama has asked states to allow insurance companies to renew non-Obamacare compliant plans through 2014. We'll be using this tracker to keep a running list of how states are deciding. For a more thorough version of this tracker, check here. And let us know if your state is missing!

Allowing late renewals: Hawaii, Ohio, N.C., Fla., Ky., Tex.

Not allowing late renewals: Calif., Mass., Md., Minn., R.I., Vt., Wash.

Still deciding: Colo., D.C., Ind., Miss., Ore., S.D.

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

Obamacare could have a huge impact on the homeless. "Housing advocates say they believe that the Medicaid expansion has the potential to reduce rates of homelessness significantly, both by preventing low-income Americans from becoming homeless as a result of illness or medical debt and by helping homeless people become eligible for and remain in housing." Annie Lowrey in the New York Times.

Key Obamacare contractor CGI had high confidence--but a low success rate. "All told, of the 45 items in which CGI had expressed high confidence at the late August meeting in Baltimore, most were still not ready by the time consumers were supposed to be able to start to buy health plans online through the federal marketplace, according to a government official familiar with the project who spoke on the condition of anonymity to discuss private information." Amy Goldstein and Juliet Eilperin in the Washington Post.

Democrats' Obamacare frustrations could boil over next month. "Some Capitol Hill Democrats are preparing to launch broadsides against President Barack Obama if the Affordable Care Act website isn’t fixed by the end of the month. That will come in the form of more aggressive scrutiny in Republican-led oversight hearings, open advocacy for further delay in the enrollment deadline and individual coverage mandate, and more calls for a staff shake-up in the White House." Jonathan Allen in Politico.