The High Stakes Effort to Implement ObamaCare

Health reform is about to kick in full force, extending new benefits and protections to citizens confused about what to expect. Fifty states must cooperate with the feds – amid partisan wars and die-hard efforts to scuttle reform. SSNers pinpoint the key issues and challenges.

The big picture

> A Field Guide to the Politics of ObamaCare Implementation
Theda Skocpol, Harvard University, and Lawrence M. Jacobs, University of Minnesota

What should we look for as ObamaCare goes forward – not just in 2014 but over the next several years?

> What Americans Really Think about Health Reform
Lawrence M. Jacobs, University of Minnesota, and Theda Skocpol, Harvard University

Most have no clue about the benefits and protections to which they will be entitled, so the challenge for public education and outreach is enormous.

> Why Health Reform Needs a Unified Approach to Outreach
Kelsey McCowan Heilman, New Mexico Center on Law and Poverty

Millions of Americans with low and moderate incomes will need personal guidance to figure out their options and sign up for Medicaid or use subsidies to buy new coverage on the state health exchanges. A one-stop, unified outreach effort will work best and save money.

> Why the Success of Health Reform Depends on Energetic and Nuanced Outreach to Latinos
Gabriel R. Sanchez, University of New Mexico

Across the United States and above all in states with high proportions of uninsured residents, Latinos are a key new constituency for expanded coverage under Affordable Care. They also strongly support ObamaCare in principle. But many do not know how to get access to the new benefits, so energetic and culturally sensitive outreach is vital – and, as this brief shows, outreach efforts will need to activate family ties and local social networks to succeed.

ObamaCare is Not That Hard to Explain!

Supporters of the Affordable Care Act have largely dropped the ball, allowing opponents to confuse the public. But the core features of the Affordable Care Act are easy to explain in everyday language.

> What Does Health Reform Do for Americans?
Theda Skocpol, Harvard University, and Lawrence M. Jacobs, University of Minnesota.

The three big things the law does that everyone needs to know.

> How ObamaCare Helps Americans Who Already Have Health Insurance
Jonathan Oberlander, University of North Carolina at Chapel Hill

Reform makes health insurance more reliable and affordable for people who have coverage at work or through Medicare.

> Debunking Common Myths about Health Reform
Katherine Swartz, Harvard University

ObamaCare furthers private insurance choices, gives states a big role, and leaves vital choices to individuals and employers. Far from bankrupting the country, reform is already lowering costs and reducing the federal deficit.

> How Mandated Auto Insurance Helps Make Sense of the Individual Mandate
in Health Reform
Jennifer B. Wriggins, University of Maine School of Law

An everyday analogy makes it easy to explain why everyone has to pitch in to pay for health care, not shift the costs onto their neighbors.

> The Moral and Economic Case for Health Insurance
Jennifer Prah Ruger, Yale University

A Florida small business owner was dead set against ObamaCare – but just one accident away from needing it herself.

Making Sure Reform Reaches the Most Vulnerable

Affordable Care promises new protections and coverage for lower-income and
middle-class Americans, including people who have had trouble getting private insurance coverage because of pre-existing health problems, and people who have had trouble getting access to good care because of where they live or the nature of their health problems. As implementation proceeds, many key steps need to be taken to ensure that reform truly helps the least privileged and most vulnerable.

> The Vital Role of Medicaid in American Health Care
Colleen M. Grogan, University of Chicago

Opponents don't want to expand Medicaid, but fully half of all Americans already have personal experience with the program or know a friend who does. Medicaid is already very popular – and well-positioned to play a big role in expanding coverage to additional millions of vulnerable Americans.

> How to Make Sure Health Reform Offers Affordable Insurance to All Low Income Families
Kelsey McCowan Heilman, New Mexico Center on Law and Poverty

Many people with incomes just above the cut-off for new Medicaid coverage will need to use subsidies to buy private plans on state exchanges. They might be tempted to buy plans with low premiums, only to discover high deductibles and co-pays when they go to the doctor or arrive at the hospital. States should take steps to help people avoid this trap.

> Community Clinics – The Hidden Health Revolution
Lawrence R. Jacobs, University of Minnesota

Poor people in urban and rural areas alike often lack access to care as well as health
insurance coverage, but little-known provisions in health reform are helping to get
care where it is needed by expanding cost-effective services offered by community health clinics.

> How Health Reform Can Help Rural Communities Improve Care for People with
Addiction Issues and Mental Illness
Cathleen E. Willging, Pacific Institute for Research and Evaluation

Reform can and must be carried through in ways that get needed medical care and social services to people suffering from mental and behavioral health problems, including those living in remote areas.

States are at the Center of Action – Or Obstruction

The Affordable Care Act launches nationwide reforms, but also calls on officials and groups in all fifty states to implement new exchanges to allow citizens to comparison-shop for private health insurance plus expansions of the Medicaid program to cover most remaining low-income people who currently lack health insurance coverage.

The original law allowed states to decide whether they would set up their own exchanges, or leave the job to the federal government. More states than expected are hanging back, but either way an exchange will function in every state. But Medicaid is a different story.

When the Supreme Court upheld the constitutionality of the law in June 2012, it also said that each state can decide without serious penalty whether to accept the Medicaid expansion. Ongoing partisan wars have led most Republican-controlled states to resist expanding Medicaid for now. Still, the issue remains contentious nearly everywhere, because hospitals, health care providers, many businesses, and consumer advocates are pressing for the planned expansion of health coverage.

SSN briefs offer a "field guide" to the overall course of implementation in different subsets of the fifty states – and also look in detail at the varied policy challenges and political conflicts affecting implementation in New Mexico, Oklahoma, Virginia, Michigan, and Hawaii.

> A Field Guide to the Politics of ObamaCare Implementation
Theda Skocpol, Harvard University, and Lawrence M. Jacobs, University of Minnesota

Twenty states are moving full speed ahead, but 25 others refuse to cooperate. The signposts of immediate success will show the different in these two sets of states.

> Why Health Reform Needs a Unified Approach to Outreach
Kelsey McCowan Heilman, New Mexico Center on Law and Poverty

New Mexico is proceeding with implementation. With 24% uninsured, the state has a huge amount to gain. But it will be challenging to get the word out to impoverished communities, including Native Americans and Hispanics living in remote areas. The best bet is a unified outreach, one-stop effort to help people learn about their options and sign up either for Medicaid or for subsidies to purchase private insurance on the exchange.

> The Oppositional Politics of Health Reform in Oklahoma
David Blatt, Oklahoma Policy Institute

Oklahoma Republicans are determined to "just say no," even though they are giving up
millions of federal dollars to help the tens of thousands of residents without health

> The Unfinished Debate over Expanding Medicaid in Virginia
Christopher Howard, College of William and Mary

Virginia Republicans are saying no, too, but the fight is far from over, because powerful hospitals, business groups, and advocates are making a strong factual case for the economic benefits of expanding Medicaid to 300,000 uninsured people.

> Halting Progress for ObamaCare in Michigan
David K. Jones, University of Michigan

With Republicans in control of a state that normally votes Democratic in national elections, the implementation of reform has divided the GOP governor from most others in his party. Governor Snyder could not persuade legislators to set up a state-run exchange, but after months of debates and votes, he finally got them to accept a delayed expansion of Medicaid to some 300,000 additional state residents.

> Idaho Republicans Decide to Build Their Own Exchange
David K. Jones, University of Michigan

Idaho is breaking the refusenik mold for Republican-led states - by agreeing to set up its own exchange and do public outreach to help its citizens purchase plans on the exchange and get access to ObamaCare subsidies for which many will be eligible.

> Will Obama's Reforms Erode Health Coverage in Hawaii?
Morgen Johansen, University of Hawai'i at Manoa

Hawaii, like Massachusetts, already insures most of its citizens, so the issue here will be
how to make sure ObamaCare strengthens rather than undermines an already inclusive
health care system.

August, 2013