A Milestone, and Miles to Go, for Obamacare

As the health care law’s first enrollment period comes to an end, advocates prepare to dive back in.

At the ready: Counselors at the San Antonio Housing Authority health fair.
National Journal
Ronald Brownstein
March 27, 2014, 5 p.m.

SAN ANT­O­NIO — The loc­al co­ali­tion work­ing to en­roll this city’s le­gion of un­in­sured in cov­er­age provided by Pres­id­ent Obama’s health care law has op­er­ated with cru­sad­ing fer­vor.

For Monday’s quasi-dead­line for the Af­ford­able Care Act’s open-en­roll­ment peri­od, the groups have sched­uled a mara­thon at the cav­ernous Alam­odome that will likely keep coun­selors at their key­boards sign­ing up ap­plic­ants un­til mid­night. “I just knew I could not wake up on April 1 know­ing that I went home at 5 p.m. on the day be­fore,” says An­drea Guajardo, the high-octane com­munity health dir­ect­or for the non­profit CHRIS­TUS Santa Rosa health sys­tem. “The ACA has the abil­ity to change the health tra­ject­ory [of this com­munity] for gen­er­a­tions.”

Few places match San Ant­o­nio in cap­tur­ing the need that in­spired health re­form — or the many chal­lenges the law faces as en­roll­ment largely con­cludes. (The Obama ad­min­is­tra­tion this week al­lowed ex­ten­sions bey­ond March 31 for those whose ap­plic­a­tions re­main un­com­pleted be­cause of tech­nic­al prob­lems.)

Lack of in­sur­ance has long burdened this work­ing-class, heav­ily His­pan­ic com­munity. In Bex­ar County, where San Ant­o­nio sits, one-fifth of all res­id­ents lack health in­sur­ance, some 340,000 people. Guajardo, who didn’t see a dent­ist un­til she was 17 be­cause she grew up un­in­sured, says cov­er­age has seemed so dis­tant that many people simply ex­pect they won’t re­ceive the care they need to avoid chron­ic con­di­tions, like dia­betes, com­mon in their fam­il­ies. “A lot of folks have ac­cep­ted the idea that cov­er­age has been out of reach for them,” agrees Rep. Joa­quin Castro, D-Texas, who rep­res­ents the city. “But that’s what the law is de­signed to change.”

Loc­ally, as na­tion­ally, ful­filling that prom­ise has proven frus­trat­ing, messy, and re­ward­ing. The corps of coun­selors log­ging long hours re­gis­ter­ing the un­in­sured points to ex­hil­ar­at­ing mo­ments of re­lief in the eyes of people who learn they can af­ford cov­er­age for the first time. Watch­ing fam­il­ies en­roll is “life chan­ging,” says Dor­is McNary, a Texas or­gan­izer for En­roll Amer­ica, the lead­ing na­tion­al group sup­port­ing re­gis­tra­tion. “You are suck­ing dirt at the end of the day, but when you lay your head down you know those kids are go­ing to keep their daddy longer.”

Yet the work of the En­roll SA co­ali­tion also re­veals the con­tinu­ing head­winds. One is res­ist­ance from Re­pub­lic­an-led states. Texas, with 5.7 mil­lion un­in­sured, has provided no sup­port for out­reach and, like about half the states, has re­fused to ex­pand Medi­caid for work­ing poor adults who make too little to qual­i­fy for the ACA’s sub­sidies to buy private in­sur­ance. In San Ant­o­nio, that de­cision has dis­qual­i­fied about half of those seek­ing cov­er­age, the co­ali­tion cal­cu­lates.

Oth­er hurdles loom. Par­tic­u­larly among His­pan­ics, many of the un­covered have no ex­per­i­ence with in­sur­ance and little un­der­stand­ing of how it could help them. While coun­selors here uni­ver­sally say the fed­er­al web­site is now work­ing well, the con­tro­versy over its launch, the pro­ces­sion of delayed dead­lines, and the per­sist­ent polit­ic­al con­flict have left many who might be­ne­fit from the law skep­tic­al. In par­tic­u­lar, coun­selors must over­come wide­spread fear that cov­er­age will cost too much, al­though for this low-in­come pop­u­la­tion, premi­ums are of­ten min­im­al after fed­er­al sub­sidies. As en­roll­ment con­cludes, it is also clear the ad­min­is­tra­tion over­es­tim­ated the abil­ity of the un­in­sured to en­roll them­selves on­line and un­der­es­tim­ated the dif­fi­culty of con­vin­cing healthy young people to par­ti­cip­ate. Both sug­gest a need for great­er in­vest­ment in out­reach and coun­selors be­fore en­roll­ment re­sumes next fall.

In all these ways, the law is emer­ging from this first open-en­roll­ment peri­od in an equi­voc­al polit­ic­al po­s­i­tion. Re­gis­tra­tion hasn’t gone so badly as to guar­an­tee its doom — nor so well as to en­sure its sur­viv­al. The dir­ec­tion of premi­ums re­mains un­cer­tain. The law faces re­lent­less res­ist­ance from Re­pub­lic­ans in the courts, the states, and Con­gress, and an in­tens­ity gap in pub­lic opin­ion. Groups that most dis­like Obama­care (such as older and blue-col­lar whites) look im­plac­ably op­posed; mean­while, sup­port­ers are still strug­gling to get young people and minor­it­ies to sign up — much less to turn out to vote in Novem­ber. Over­all “at­ti­tudes about the law seem stable and neg­at­ive,” says GOP poll­ster Bill McIn­turff.

Giv­en those dy­nam­ics, Demo­crats might jus­ti­fi­ably ask wheth­er their pur­suit of uni­ver­sal health care has pro­duced more be­ne­fits or costs. Bill Clin­ton’s un­suc­cess­ful re­form push helped trig­ger the 1994 GOP land­slide that gave Re­pub­lic­ans al­most un­broken con­trol of both con­gres­sion­al cham­bers for the next 12 years; the back­lash against Obama’s plan helped Re­pub­lic­ans win the House in 2010 and could help de­liv­er them the Sen­ate in Novem­ber. Ab­sent those losses, Demo­crats might have passed many of their oth­er pri­or­it­ies, from im­mig­ra­tion re­form to uni­ver­sal preschool.

Health re­form won’t jus­ti­fy those costs un­less Obama can polit­ic­ally en­trench it be­fore he leaves of­fice, mostly by cov­er­ing more of the un­in­sured. In San Ant­o­nio, ad­voc­ates hope to ul­ti­mately en­roll about one-fourth of those eli­gible this year. But they also view that as just the first stage of a long march. “After March 31, we will take one minute to break,” Guajardo says, “and then we will start plan­ning for next year.”

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