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Obamacare’s Nine Lives

If Obamacare survives the latest Supreme Court challenge, it will really be the cat with nine lives.

The death of what became the Affordable Care Act has been predicted regularly ever since President Obama’s election in 2008. Right afterwards, I got a wave of calls from reporters, each highly skeptical that the president-elect would really try to get health care passed. When you consider the relentless attacks and near-death experiences ever since, the reporters’ skepticism was understandable.

So when I found myself with a fresh surge of anxiety before the Supreme Court heard oral arguments in March on the latest assault on the law, I decided to list all the times that the survival of the Act was up in the air. And when I then counted them, it turned out that they numbered eight. So if Obamacare survives this last, desperate challenge in the Supreme Court, it really will have nine lives. Here they are, in chronological order:

1. The Great Recession: After Obama’s election a chorus of pundits predicted that the new president would have to give up his promise of health care reform because of the economic crisis. Instead, the president worked to get the economic stimulus passed, while paving the way for health reform. Just a few weeks after the stimulus became law, the president went on a national tour to push for action on health care.

2. Tea Party August: The Tea Party movement came to national attention with loud, vitriolic attacks on health care at congressional town meetings held by Democrats in August 2009. Republicans gleefully predicted they had killed the bill. But by the second half of August, supporters of health reform had rallied at dozens of town hall meetings, usually turning out more activists than the Tea Partiers. The press didn’t give the same attention to meetings that were not marked by raucous demonstrations. But Democratic lawmakers were sent back to Congress knowing they had support in their home districts to move ahead.

3. Scott Brown’s Election: The surprise election of Republican Scott Brown to the U.S. Senate in January 2010, on a platform opposing health care, looked like it might kill the bill. But having voted to pass the legislation in both houses, Democrats were not going to turn back. President Obama rallied the public by finally attacking the practices of health insurance companies and even without a filibuster-proof majority in the Senate, the Patient Protection and Affordable Care Act became law.

4. The Supreme Court Challenge: Immediately after the ACA’s passage, opponents launched a legal attack, which – shocking most legal scholars – was taken seriously by the courts. And by the time the Supreme Court heard the challenge, the odds were that the Court would gut the key provision of the law that enabled insurance to be affordable to individuals. But Chief Justice Roberts saved the day  – and much of the Court’s credibility.

5. The 2012 Election: If the Senate had gone Republican in 2012 – as was widely predicted – and Mitt Romney been elected, Obamacare would have been repealed. Instead, the ACA emerged with a new electoral mandate.

6. Government Shutdown and Congressional Repeals: I hesitated to put the 50 or so Republican votes to repeal the law, culminating in the government shutdown in the fall of 2013, on the list, only because of President Obama’s veto pen. But even if the ACA always had the presidential veto as armor, the barrage of repeal missiles has got to be counted. Texas senator Ted Cruz led the government shutdown before health insurance enrollment opened up because, as he said, “no major entitlement has ever been implemented and then unwound.”

7. Healthcare.gov: And then, with the disastrous launch of the website to enroll people in health care, Ted Cruz appeared to have gotten his wish fulfilled. The ACA might not be legally dead, but much of it was functionally comatose. Then the administration resuscitated the website, and millions were enrolled and started benefiting from the coverage. It looked like, as Cruz feared, the ACA was here to stay.

8. Supreme Court Redux: That is until the Supreme Court agreed to hear a desperate, last-minute challenge to the ACA’s subsidies for millions of newly enrolled people in the King v. Burwell case. Could this be like one of those movies where the soldier survives the war, only to be killed by a bullet on his way home, fired by an enemy that hadn’t heard the war was over?

The news reports of the oral arguments were encouraging, particularly Justice Anthony Kennedy’s raising of a constitutional issue with the plaintiff’s case. And there are a host of other legal reasons to believe that the lawsuit is groundless. But then it did get this far. The opponents have been relentless. They haven’t gotten the message that the war is lost.

In June, we’ll find out if the ACA is indeed the cat with nine lives. Easy to laugh at, if not for the fact that the actual lives of millions of people who rely on the law for life-saving health care are at stake.

Richard Kirsch is a Senior Fellow at the Roosevelt Institute, a Senior Advisor to USAction, and the author of Fighting for Our Health. He was National Campaign Manager of Health Care for America Now during the legislative battle to pass reform.

This was originally published in Next New Deal, the blog of the Roosevelt Institute.

Photo: Mark Hillary via Flickr

Weekend Reader: ‘America’s Bitter Pill: Money, Politics, Backroom Deals, And The Fight To Fix Our Broken Healthcare System’

The Affordable Care Act — Obamacare — is the most heralded and condemned legislation of the decade. The labor of accomplishing nothing less than a complete overhaul of the disastrous state of American healthcare has been hindered every step of the way by bellicose partisan discord, rabid lobbying, and the cataclysmic launch of a defective website.

How Obamacare came to exist and why it continues to struggle to achieve its aims is the subject of Steven Brill’s America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System. A comprehensive chronicle of the law’s trajectory — the demand for it, the drafting of it, the implementation of it — America’s Bitter Pill is an assessment of its successes and failures, and of how far we have to go.

You can purchase the book here.

In June 2013, I came up with what I thought was a great idea for another special report for Time. As with that earlier story, this one was born of simple curiosity.

I had gotten the idea for the first article when I became curious because so much of the debate over Obamacare seemed about how we could insure millions of Americans against the stupendously high cost of healthcare in the United States, rather than why the cost was so high to begin with. What and who was behind all of those high prices? Where was all that money going? To find out, I would trace the money and profits behind every line item in hundreds of pages of bills given to seven patients.

Now, I told my editors, I was curious about something else: Launching Obamacare, with its e-commerce insurance exchanges and thousands of other complexities, seemed like the most ambitious domestic government project since Medicare. In fact, it was going to be far more difficult, I pointed out, to pull off than Medicare. Medicare was about getting an identifiable subset of the population to sign up to get something for free. With Obamacare, people had to be sold on buying a confusing product and given exactly the correct subsidy to do so. Even those that didn’t buy — all adult Americans — would somehow have to prove that they had insurance, and employers would have to prove that they were providing it to their workers.

How were they going to do all of that?

So we had agreed that through the summer I would make multiple trips to Washington to look in on how this massive program and its core e-commerce website was being built. I even told my editors that based on the efficient, dedicated people I had seen at the CMS campus in Baltimore while reporting on the vetting and processing of Alan A.’s Medicare bills for the first article, this was likely to be an uplifting saga of unsung heroes. Whatever the political dysfunction in Washington, Obama’s managers and these civil servants were going to prove that big government could work.

The story would come out in late October, after what I thought would be a triumphant launch.

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Who’s In Charge Here?

As I was returning from my first round of interviews that plotline started to blur. On the train back to New York, I flipped through the notes I had taken while talking with eight people who were working on the project at the Department of Health and Human Services, CMS, and the White House. I saw that almost as an afterthought or conversation starter I had asked each who was the person in charge of the launch of the federal exchange. I hadn’t paid much attention to the answer, until I sat on the train reviewing the notes.

There were seven different answers:

Jeanne Lambrew at the White House;
Michelle Snyder, who ran CMS operations;
Gary Cohen, who ran CCIIO—the Center for Consumer Information and Insurance Oversight that had been demoted from being an office; he got two votes;
Marilyn Tavenner, the head of CMS;
Kathleen Sebelius, the HHS secretary;
Henry Chao, the deputy director of the CMS technology office;
And David Simas, who was overseeing the marketing and messaging of the launch from the White House communications office.

I also noticed that I had asked a spokesman for CMS, who was taking me around for interviews, who was in charge. Now I saw that he had said, “It’s kind of complicated.” Whereupon he had taken my notebook and drawn a diagram with four diagonal lines crossing one another and forming a kind of lopsided triangle. It was incomprehensible.

Finally, my notes reminded me that when I had asked one person at CMS if I could watch the October 1 launch from their control room or command center or whatever they were going to call it, she had responded, “Which one?” There were actually going to be four or five command or operations centers, she had explained: one for each of three CMS offices, another at HHS, and maybe another at the White House.

When I got home that night I told my wife that I was not so sure I was going to be able to write the launch saga I had sold the Time editors on. The launch looked like it had problems.

If you enjoyed this excerpt, purchase the full book here.

From the book America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System by Steven Brill. Copyright © 2015 by Brill Journalism Enterprises, LLC. Reprinted by arrangement with Random House, an imprint of Random House, a division of Penguin Random House LLC. All rights reserved.

Obama’s Approval Rating Improves As Healthcare Drag Eases

By David Lauter, Tribune Washington Bureau

WASHINGTON — President Barack Obama’s job approval ratings have improved, if only slightly, from a low point during the winter, a trend that potentially could help embattled Democrats in key Senate races this fall.

The size of the change varies from poll to poll, but they tell the same overall story: Obama’s ratings took a slide in the fall as the public saw his HealthCare.gov website flounder. More recently, with the website fixed and the news about the president’s health care law focusing on millions of people enrolling, his approval numbers have recovered.

That improvement could matter because how voters feel about the president has an effect on how they vote on members of the president’s party. This fall, control of the Senate will be up for grabs, and during the winter, Obama’s slide in the polls was one factor in an improvement of Republican chances.

George W. Bush provides the example Obama hopes to avoid. Bush’s approval began to plummet after Hurricane Katrina in late summer 2005. It continued to drop through the spring of his sixth year in office as the public absorbed steady bad news about the war in Iraq, reaching the low 30 percent range in Gallup’s surveys.

That slide helped create a political climate in which Democrats scored a major victory in the midterm election.

For a while in November and December, Obama’s approval copied Bush’s trajectory. But more recently, the president has done better. His approval rating hit a low point of about 40 percent in December, stabilized and then began to rise a bit. Over the entire first quarter of this year, his approval has averaged just more than 42 percent in Gallup’s polling and last week hit 45 percent, the firm reported. Unlike Bush, he has not experienced a sharp decline in support within his party.

Still, Obama’s current ratings are low, in comparison with his record and with that of most of his predecessors. At its current level, he may not be weighing down Democratic candidates, but the public’s view of him would have to improve more before he would represent a net positive.

Democrats have an additional problem in the Senate because, by luck of the draw, the highly contested races this year almost all take place in conservative states, including Alaska, Arkansas, Louisiana and North Carolina, where Obama’s popularity is lower than it is nationwide.

AFP Photo/ Robin van Lonkhuijsen

Medicaid Programs Drowning In Backlog

by Charles Ornstein, ProPublica.

Last week, federal health officials celebrated two milestones related to the Affordable Care Act. The first, which got considerable attention, was that more than 7 million people selected private health plans in state and federal health insurance exchanges. The second, which got less attention, was that some 3 million additional enrollees had signed up for Medicaid and the Children’s Health Insurance Program (public health insurance programs for the poor), many as a result of Medicaid’s expansion.

But there are growing signs that Obamacare’s Medicaid expansion is a victim of its own success, unable to keep up with demand. While about half the states have refused to expand their Medicaid programs’ eligibility, among those that have, some can’t process applications fast enough.

Media reports from New Jersey, Illinois and California (states that have expanded their Medicaid programs) show that hundreds of thousands of consumers who may qualify for new Medicaid coverage aren’t getting it.

So what’s happening?

In Illinois, the Chicago Tribune reported last month that there’s a backlog of more than 200,000 applications waiting to be processed.

Illinois officials initially expected 200,000 people to sign up for Medicaid under the expansion in 2014. But through last week, more than double that number have applied. And amid a marketing blitz, officials expect a surge of additional applications by the end of the year.

Unlike new commercial insurance products, which consumers can purchase through March 31, there’s no deadline to sign up for Medicaid. By the end of the year, state officials expect about 350,000 new users to be enrolled in the program.

The growing backlog is causing concern among health care providers worried about getting paid, and confusion, frustration and anger among consumers, whose coverage was supposed to begin in January.

Much the same thing is happening in New Jersey, the Star-Ledger reported last week.

By all accounts, enrollment in the expanded Medicaid program has gone well in New Jersey. The numbers are robust as the program’s expansion under the Affordable Care Act allows single residents and childless couples to get coverage provided their income is low enough. But getting an actual ID card that allows someone to see a doctor? The flood of applicants appears to have resulted in a systemwide backlog, according to applicants and field workers.

“I’ve heard getting an actual Medicaid card is nearly impossible. It’s like getting Willy Wonka’s Golden Ticket,” said Rena Jordan, director of external affairs for Planned Parenthood of Metropolitan Jersey, which has been helping patients enroll.

“A lot of strange things have been happening, that’s the easiest way to say it,” said Virginia Nelson, administrative supervisor of the Medicaid Department for Middlesex County.

The flood of phone calls to her office about older cases has taken time away from processing the newest cases, Nelson said.

Federal officials conceded some of the blame for the delay can be put squarely at the feet of the federal website, HealthCare.gov. That website transferred data about applicants whose income looked like they might qualify for Medicaid to the state system, but in a format the state system couldn’t use.

And in California, the backlog now numbers 800,000 for Medi-Cal, the state’s Medicaid program, the Los Angeles Times reported this week.

One patient wrote The Times to say she has a worrisome growth behind an ovary. She submitted an application in October. County health clinics informed her she won’t be able to keep her appointments for blood tests and ultrasound scans until her Medi-Cal coverage is confirmed, she said. Or she can pay full price for the services.

As of Thursday, she was still waiting.

“A lot of good, smart people with good intentions in the state and county are working really hard to fix these problems,” said Katie Murphy, managing attorney at Neighborhood Legal Services of Los Angeles County, which has a grant from the state to provide legal assistance to patients with Obamacare enrollment cases. “But until they do, people will fall through the cracks.”

A state spokesman told the paper that “the volume of Medi-Cal applications, combined with challenges of new computer systems, hampered the state’s ability to complete eligibility reviews in a timely and accurate manner.”

Matt Salo, executive director of the National Association of Medicaid Directors, said many of the problems relate to the way HealthCare.gov transfers information to states about consumers who appear to qualify for Medicaid based on their incomes. But there are state-specific issues, as well.

“It’s been the number one issue of concern for our members for the past nine months or so,” he said in an email. “The problems are getting fixed, but what worries people is that we’re only a few months away from NEXT year’s open enrollment, so we have to hurry.”

AFP Photo/Joe Raedle