What needs to happen for Obamacare to survive 2014

healthcare.govThe Affordable Care Act is a law intended to help the sick get the healthcare they need at a reasonable cost. But, as we’ve heard time and time again, the law itself is ailing. Some pundits have said the law will most certainly be repealed in 2014, while others cling to the theoretical good it may be doing for some Americans. More still swim through dates and deadlines, wondering when (or if) they need coverage and what kind and whether they’ll be able to keep their doctors and plans.

The ACA has had a rough rollout, by all accounts.  Very little Obamacare news has been good news. Here are six things that need to happen for Obamacare to survive 2014 and potentially thrive without a major operation, a defibrillator or an oxygen tank.

1) Seven million consumers by March 31, 2014.

The Republicans have said 7 million must be reached for the markets to succeed. The White House has said 7 million is just a number filled with optimism. Both are wrong at this point.

To the Republicans’ point, the actual number 7 million has very little (if anything) to do with whether the marketplaces will bear their own weight. The ratios of who is in each market (more on that later) are much more important than how many. An overstatement that illustrates this point:

“I don’t know why they embraced 7 million people,” one insurance industry insider told Politico. “It was just another opportunity to disappoint people. Five million of a good mix is way better than 7 million old, sick people.”

The reason why is because this is the number the Congressional Budget Office laid at the administration’s feet. It gave a tangible goal to complicated legislation. HHS Secretary Kathleen Sebelius herself used the number in defining the program’s success.

This is why the White House is wrong, too. At this point, it’s not just the markets that need to work. The public’s faith in the Affordable Care Act needs serious rekindling (as in, “Grab the lighter fluid!” levels of rekindling).

For the sake of the rollout meeting one major goal, 7 million is a number that must be hit.

The Wall Street Journal reports WellPoint plans to spend $100 million on an ad campaign targeting Young Invincibles by the end of 2013, and TVB estimates insurers will spend $500 million on TV ads for the exchanges in 2014. This could contribute to a surge in the number of enrollees.

2) And of those 7 million, Young Invincibles better show up.

BrobamacareYou’ve heard it time and time again: Healthy young enrollees make Obamacare work (more specifically, they level the health insurance exchanges marketplace to pay for the older, sicker enrollees). If the number’s 7 million, more than 2.5 million, or more than a third, need to be Young Invincibles.

If the 7 million mile mark isn’t passed, that ratio still needs to hold true for the premiums to stay down. And not just in the federal exchanges. In every state. (Even though now it seems even the ratio bar is being lowered.)

But for that goal to be reached, the White House team should nix its current waterlogged, dumbed-down campaign strategies and think up something substantive. More on why the bro-filled ads and Jennifer Hudson sleuth videos aren’t cutting the mustard with Millenials like me or my colleague Deanna here.

3) States with Medicaid expansion need to do better than those without the expansion.

The disparity the coverage gap causes in states that have chosen not to expand Medicaid is frightening. In those 23 states combined, 4.6 million uninsured who fall under the federal poverty line will be too poor to receive aid under Obamacare and too rich (sigh) to receive Medicaid.

Figure 1: In states that do not expand Medicaid under the ACA, there will be a gap in coverage available for adults.

But it is likely those states will blame the legislation rather than the states themselves for this gap. (Wrong-minded, sure, but that hasn’t stopped voters for centuries.)

This means the states that have chosen to expand Medicaid need to fly. My homestate of Kentucky, which is implementing the Medicaid expansion in 2014, is soaring. Never before its health insurance marketplace have I witnessed Kentucky being touted so as a media darling in a context that did not involve an orange ball, fast horses or George Clooney. While I would like to say the best state in our country could hold a national program together, it’s going to take this level of success from each state that implements the expansion next year.

It doesn’t matter if Medicaid actually has anything to do with a particular problem. The states with the expansions will be the ones thrown into the fire. The success stories need to overshadow the negative press.

Which leads me to my next point.

4) No more missed deadlines. No more retreating.

With the deadlines for getting covered by Jan. 1 now muddled due in large part to The Glitchy Website That Shall Not Be Named, the sad attempt at promising the unpromise-able and the delay of the employer mandate, the ACA is less than a tenth of a second from a plain ole shot-clock violation. (FYI: You can sign up until Dec. 23 to get coverage beginning Jan. 1. You need some sort of health insurance by March 31 if you don’t want to be penalized.)

Effective Jan. 1, 2014, there can be no more delays, no more missed deadlines. The hefty law needs to gather its weight and get moving to create serious momentum to push it into 2015.

5) The website needs to be passable. Not fantastic, just one that works consistently. We shouldn’t ever hear about it again after Jan. 31.

Former Microsoft Office President Kurt DelBene will join Jeff Zients in scurrying to fix The Glitchy Website That Shall Not Be Named. Zients’ will be appointed as the White House’s chief economic advisor in February.

Things like this cannot keep happening.

After Jan. 31 (and all those New Year’s reels sure to be filled with the “Obamacare girl’s” face), the ACA’s proponents should avoid talking about the website again at all costs. Move on to the real stats, talking about state ratios and who the bill is helping. Keep the emphasis on an unsuccessful tech launch and no one will remember how the bill works, only that the website didn’t.

6) President Barack Obama needs his base to stay galvanized, and well, just to stay.

Finally, President Obama needs to find a way to protect the Democrats during the mid-term elections, shielding them from any Obamacare blowback. (Was it only two months ago some Republicans feared the repercussions of another GOP-led government shutdown while Democrats made snide asides?) Losing core supporters likely would spell M-A-N-D-A-T-E to the repeal-hungry, even if there are only small losses in small districts, even if that mandate is weak and not nearly resounding.

The setbacks, the glitches and lie, the judicial issues and problems the ACA has faced will put some seats up for grabs. If Obamacare has a survival instinct, the White House will have to fight for these incumbents with all its might. (I anticipate the POTUS Traveling Roadshow will have more episodes than usual this spring.)


I’m of a mind that says Obamacare’s survival is possible and probable. The answer yet to be seen is whether the law’s existence, in piecemeal, part and parcel, will be meaningful, will remain more a policy than a 2,000-plus page tome saying Americans mostly agree universal healthcare might be nice.

Meanwhile, as Dan Munro points out, we’re still arguing over who gets covered without tackling cost.

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