THOUGHT YOU HAD seen the last of the fighting over the Affordable Care Act, also known as Obamacare? Since its passage in 2010, after all, it has survived Supreme Court review, innumerable challenges from House Republicans and Mitt Romney’s unsuccessful campaign to evict its author from the White House.
Nonetheless, with the heart of the reform set to take effect next year, its most contentious days may lie ahead. The law will affect Americans’ health and pocketbooks, and its implementation entails many challenges and quite a few unknowns. Republicans are hoping to ride the inevitable glitches and setbacks to electoral success in 2014. Many Democrats say the critiques are overblown — but still worry about both the politics and the practical obstacles to rolling out such a complex law.
For starters, many Americans don’t know much about what’s coming. According to a recent Kaiser Family Foundation poll, a fifth believe that either Congress or the Supreme Court has killed the law. Some of them may be surprised to discover that they are required to buy health insurance on new exchanges beginning Jan. 1, 2014.
President Obama last month said nothing will change for the 85 to 90 percent of Americans who have insurance. That’s not quite right. Even some people who are currently insured may see premium increases — or, depending on their health, gender and age, reductions. For example, the 10 percent or so who are in the individual insurance market will shop at “exchanges” — new health-care marketplaces for individual purchasers — where the currently uninsured also will go. The law protects the old and the sick, but that also means that some of the young and the healthy might have to pay more than they do now, particularly if price-control mechanisms don’t work as well as hoped. How many will sign up?
Merely setting up the exchanges is a massive job. There is not much time left to get the technology just right — integrating private insurance company systems with state and federal exchange Web sites and the Medicaid system. Republican-led states refusing to help implement the law make the task even harder.
There is also concern that the law will affect hiring decisions. It requires any company with 50 or more full-time employees — or the equivalent in part-time workers — to offer health coverage or pay a penalty. Will some companies cut hours to avoid being subject to that mandate? Will some choose not to hire that 50th employee? Perhaps, say some of the law’s backers, but the universe of firms in the position to make these sorts of choices might also be relatively small.
A significant potential problem in implementation stems from the Supreme Court ruling. Obamacare expected to achieve its goal of near-universal health-care coverage in part by inducing states to expand their Medicaid programs. The court, in an opinion written by Chief Justice John G. Roberts Jr., ruled that the states could decline to do so. Many states have taken the court up on its offer, though it means turning down massive federal subsidies — and leaving nearly 8 million low-income Americans without health-care coverage, more than 2 million of them in Florida and Texas alone.
Even many strong supporters admit that there might be some bumps in the road ahead. Problems shouldn’t be swept under the rug. But nor should the law’s noble and useful goal: ensuring that as few Americans as possible go without health care.