Obamacare: He Built It. But Will They Come?

Enrollment for health insurance under the Affordable Care Act (ACA), popularly known as “Obamacare,” began on October 1, in preparation for the official launch of the new insurance plans on January 1, 2014. Yet the massive overhaul of the nation’s health care system faces almost as many questions and challenges now as when it was first enacted. Republicans in Washington and in many states continue to fight its implementation tooth and nail; congressional Republicans even forced a shutdown of the federal government this October in an effort to derail the law.
Meanwhile, many of the very Americans the law is designed to help are skeptical or simply unaware of its potential benefits. Obamacare’s fate, as well as its namesake’s legacy, will depend on the ability of its supporters to reach and to persuade such Americans in the coming months.
Passing the Buck—and Passing Up the Bucks
Many Republican governors and state legislatures have refused to set up the Obamacare “exchanges”—online marketplaces that connect uninsured Americans with providers. Republican governors may stand to gain politically from their uncompromising stance on the exchanges. They can wash their hands of Obamacare, blame the federal government if anything goes wrong, and score points with their right-wing base. However, their actions contradict the conservative principle that states should be allowed to act as laboratories of democracy and tailor federal programs to the needs of their citizens. Ironically, the states’ refusal means that a majority of the exchanges are instead run by the federal government. Paul Ginsburg, an economist and president of the Center for Studying Health System Change, explained to the HPR that “Democrats in the House preferred an entirely federal exchange” and provided for one in the original, more progressive legislation initially passed by the House.
From the perspective of the Obama administration, the states’ rejection of the exchanges is a mixed bag. It increases the logistical and financial burden on the Department of Health and Human Services (HHS), but it also empowers the federal government to establish a more progressive model for the exchanges. Yet given a lack of funding, Harvard health economist David Cutler told the HPR that “it will be very interesting to see if … the law has a more salutary effect in, say, California than in Texas.” If the federal government cannot effectively fill in for the states, the quality of coverage may be lower in states that have resisted setting up the exchanges.
In addition to declining to set up exchanges, many Republican governors have refused the ACA’s Medicaid expansion. Cutler argues that this is a far more serious problem than their intransigence on the exchanges, since “they’re hurting real people… who are, according to the federal government, eligible for coverage that would cost the state nothing.” Given that the federal government would fully pay for the first three years 
of the Medicaid expansion before reducing its subsidy to 90 percent by 2020, Cutler views the opposition as motivated by political, rather than fiscal, concerns: “It’s interesting to see how many people they are willing to kill in order to make clear the fact that they hate the president,” he bluntly observed.
In a more encouraging sign for the low-income uninsured, several Republican governors, especially swing-state governors such as John Kasich of Ohio and Rick Snyder of Michigan, have agreed to accept the federal money and expand Medicaid. Meanwhile, Harvard government professor Theda Skocpol told the HPR that some swing-state Republican governors who have refused to expand Medicaid, such as Paul LePage of Maine, will likely lose in 2014, “paving the way for those states to accept the expansion.”
“Let the People Know the Facts, and the Country Will be Safe” – Abraham Lincoln
Ultimately, however, the most daunting challenge facing Obamacare and its proponents may simply be the fact that many uninsured Americans remain skeptical of the law and unaware of its potential benefits. A September NBC/Wall Street Journal poll found that “among the uninsured, 76 percent of respondents said they didn’t understand the law and how it would affect them,” while “only 32 percent of the uninsured thought they were ‘fairly’ or ‘very’ likely to use the exchanges.” To place these numbers in context, Cutler estimates that Obamacare “will be phenomenally successful if we get [60 percent enrollment] or more,” but that “we will be in big trouble if we only get half that enrollment.”
It is especially crucial that a sufficient number of young people sign up for health insurance. If young, healthy people decline insurance and the pool is composed primarily of older people with higher medical costs, premiums could skyrocket—a problem known as adverse selection. A September Reuters/Ipsos poll found that uninsured millennials tend to be more supportive of Obamacare than the general population, and many young adults who previously lack information regarding the exchanges are persuaded to sign up when presented with basic information.
Millennials’ receptivity to the exchanges is a great source of hope for Obamacare proponents such as Enroll America. A nonprofit with ties to the Obama administration and the health care industry, Enroll America is conducting a campaign-style effort to reach uninsured Americans and persuade them to sign up. Enroll America’s leaders are no strangers to campaigning: its president, Anne Filipic, launched her career as Obama’s field director for the 2008 Iowa caucuses. Like a political campaign, Enroll America plans to spend millions on advertising and is launching a broad canvassing program to persuade uninsured Americans in Republican-controlled states of the law’s benefits.
Outreach efforts received a boost in August, when HHS announced $67 million in grants to community groups, health care providers, and other organizations to hire “navigators,” tasked with educating the uninsured about the options available to them through the exchanges. Yet the navigators themselves are encountering resistance and interference from some states. Indiana has required navigators to pay a licensing fee of up to $175 and undergo a criminal background check, while Florida has banned navigators from local public health offices.
Meanwhile, outside conservative organizations have launched campaigns of their own, with the goal of persuading uninsured Americans to “opt out” of Obamacare. Harkening back to the anti-Vietnam protests of the 1960s, FreedomWorks is creating fake “Obamacare cards” and encouraging its supporters to burn them. According to The Washington Post, FreedomWorks Vice President Dean Clancy stated that the purpose of this symbolic gesture is to “make it socially acceptable to skip the exchange and pay the fine.” Unsurprisingly, Obamacare’s opponents are tailoring their message to the young people whose participation is critical to the law’s success.
A Presidential Legacy in the Balance
Apart from the campaign-style efforts of each side, a variety of simple behavioral factors could determine whether uninsured Americans are persuaded to sign up. Kevin Volpp, a behavioral economist at the University of Pennsylvania, told American Public Media’s Marketplace that, in keeping with the theory of “loss aversion,” the penalty for failing to purchase insurance may motivate many Americans to sign up. However, Ginsburg contends that “the penalties are not substantial enough” to act as a serious motivator and “need to be stronger.”
On the other hand, some uninsured Americans may buy insurance simply because it is the law. Ginsburg believes that the stigma associated with breaking the law “was a motivator in Massachusetts,” though he cautions that “the highly charged environment with active opposition to Obamacare could make this less of a factor.” Harvard behavioral economist David Laibson suggested to the HPR that in places where “not going along with Obamacare is being framed as doing the right thing,” people may be emboldened to disregard the requirement.
In the end, Cutler stresses that “affordability and accessibility are the two most important” determinants of whether people will buy insurance. In an attempt to increase affordability, the law does offer subsidies to individuals and families with incomes up to four times the federal poverty level. However, familiar problems emerge: while almost 26 million Americans could be eligible for subsidies, many are unaware of the potential assistance. As a result, the Congressional Budget Office estimates that only 6 million will actually receive subsidized coverage through the exchanges in 2014.
Enrollment will likely proceed in waves, rather than at a steady pace. There was an initial rush when the exchanges first opened on October 1. There may be a second spike in enrollment around the December 15 deadline to receive benefits starting on January 1, 2014. Finally, it is expected that some will sign up just before the March 31 deadline to avoid the penalty on their tax forms. Throughout this process, both proponents and opponents of Obamacare will be watching closely to gauge the pace of enrollment. Any sign of lagging enrollment will be pounced upon by opponents as proof that the law is failing, while robust early enrollment may spur further enrollment, laying all doubts to rest early on.
Implementing a reform on the scale of Obamacare has never been easy. Logistical difficulties are inherent in such a massive undertaking. Nor is Obamacare the first social reform legislation to face sustained opposition after its passage. Skocpol observes that Social Security, now largely taken for granted, also faced “efforts to delay or fundamentally revise it” for the first 15 years of its existence. 
While Obamacare’s opponents could be fueled by any number of motives, it seems likely that they are animated at least in part by the recognition that the ACA’s success or failure will have profound implications for Obama’s legacy. Depending on how Obamacare fares in the coming years, Obama may yet be remembered as a transformative leader, or he may be derided as one with a grand vision but little ability to implement it. Moreover, the law’s foes surely realize that they face a closing window of opportunity to kill it. Skocpol predicts that by 2016, Obamacare will be firmly established. Once previously uninsured Americans have experienced two years of benefits and subsidies, “you can’t take it away,” she explained.
Amidst all the opposition and uncertainty, there appears to be at least one silver lining for Obama and the proponents of health care reform: the greatest threat to the law’s success is likely not the organized opposition, but the simple fact that many uninsured Americans are not yet fully aware of its benefits. Unlike Obamacare’s most vehement opponents, they are likely persuadable, and more interested in securing affordable care than in waging partisan battles. If the proponents of Obamacare can effectively inform the uninsured, they will surely come.