The University of Chicago

School of Social Service Administration Magazine

Volume 20 | Issue 2 | Summer 2013
Complicating Factors To succeed, Obamacare will need to get past three big hurdles in implementing state exchanges

The Patient Protection and Affordable Care Act (ACA) has already survived a bruising fight through Congress, a legal challenge before the U.S. Supreme Court, and promises of repeal by the 2012 Republican candidate for president. Its biggest test, however, might be yet to come.

There’s no guarantee that the health insurance exchanges—the state-based marketplaces where eligible consumers will be able to purchase government regulated insurance plans—will be ready by the date they’re required to open: January 1, 2014. If that happens, the fate of the ACA would be in grave jeopardy, warns Henry Aaron, who presented the closing address at “Equity and Choice in Health Care Access,” a conference at SSA that commemorated the 50th anniversary of the Center for Health Administration Studies.

“The deadlines are tight; there’s no slack,” says Aaron, the Bruce and Virginia MacLaury Senior Fellow in the Economic Studies Program at the Brookings Institution. “We’ve got to be both good and lucky.”

Aaron cites three major hurdles for ACA to perform as designed. For starters, the federal government and the 25 states that voted to open health exchanges will need to set up the infrastructure. That means purchasing computers, coding software and rewriting local regulations to comply with new national mandates.

Next, government officials will have to explain and advertise the benefits so eligible Americans and small businesses sign up. According to one poll, 78 percent of the uninsured likely to qualify were unaware of the new options. “For those who are being nudged into the system,” Aaron says, “I think it’s going to be a steep period of learning.”

Lastly, regulators will likely confront a host of administrative challenges: determining eligibility, keeping track of how insurance applies to family members, computing subsidies and sending premiums to the correct insurers.

The bitter political atmosphere on Capitol Hill will complicate implementation. When Massachusetts rolled out its universal health care program in 2006, Aaron says glitches were dealt with swiftly. “You had bipartisan agreement, and you had labor-management agreement,” he says. That’s not the case for the ACA, where political opponents will likely publicize every minor mishap. “What I’m concerned about is that the spirit—that we can fix it and we want to—will be in scarce supply,” he says.

Aaron is convinced officials inside the administration realize how difficult their endeavor is. “They won’t stint in doing what they think needs to be done in order to get this out,” he says. The Centers for Medicare and Medicaid Services $3 million marketing blitz is expected to ramp up this summer, and several states have also tapped top advertising firms to help get the word out. Aaron says the hope is that political gamesmanship will subside when a few states hit the ground running and their residents express general satisfaction with how the system works. --Adam Doster