Love it or leave it health care

Insurance sign-ups are being targeted at both national and state levels

While the Obama administration battles with the Republican House of Representatives this summer in the public relations fight over getting people to sign up for the new health care insurance coverage, key decisions affecting millions of poor folks are being made at the state level with major consequences.

Supporters and opponents are squaring off in efforts to sell or roll back the implementation of the Affordable Care Act, known as “Obamacare.” Both sides want to get the tactical advantage in advance of when people start to sign up for health insurance plans in October.

The Obama administration is preparing to carry out the president’s landmark health care reform law. To them, this is a fight for his political legacy. On the other side are House Republicans, conservative groups, some GOP governors and tea party affiliates. They are determined to make the repeal or severe crippling of the Affordable Care Act (ACA) their top priority with the 2014 midterm elections as their prize if successful.

The Feds: Bring it on

To get their supporters active and excited, administration officials are planning a series of initiatives aimed at using social media, websites and door-knocking neighborhood campaigns to help people who might benefit from the legislation, along with efforts to target Spanish speakers and young people, to convince the uninsured to buy insurance when it becomes available on October 1.

While rallying their political base is the goal for Republicans, there are many ways they can cause problems for the Democrats. The GOP continues to try to restrict or cut back funding and stymie efforts to implement the law as a way of whittling away at the law’s impact.

The number is 37: that’s how many times House Republicans have passed legislation to repeal the health care law since it became law three years ago. While any repeal legislation would ultimately need Obama’s signature – something that will not happen – the political exercise by the Republicans jazzes up their political base, and energizes their supporters to turn out in the 2014 elections when the entire House of Representatives is up for re-election along with a third of the U.S. Senate.

Scarred by years of Republican attacks over the health care law, with more in store next year, Democrats have settled on an unlikely strategy for the 2014 midterms: bring it on.

In 2010, Republicans pointed to the health care law as the primary example of big government run amok. Now Democrats are embracing the polarizing law with renewed vigor, despite difficulty getting the public to appreciate the potential benefits of the law. They are pushing forward with implementing the law as states decide whether to set up their own insurance marketplaces or let the federal government do it. Democrats hope to sign up as many as seven million Americans over the next year.

They will roll out, a website designed to make it easy for people to sign up and compare insurance plans. Health and Human Service Department officials have simplified complex forms into easy to use online forms. Recently, House Minority Leader Nancy Pelosi, D-Ca., distributed a 78-page binder instructing members on how to sell the bill in their districts.

A big focus will be to target minorities and young people, the groups most affected by a lack of insurance. Young people, the so-called young invincibles, who are unlikely to make health insurance a priority, hold the key to the law’s success. They might be some of the least likely to sign up, but they’re the most highly sought-after customers: Their health status will balance out the sicker and more costly individuals. If only the latter enroll, the exchanges could tank.

The Republican agenda is to continue to repeal all of Obamacare and to point out to anyone who will listen just how bad the president’s health care law will be for the country. No surprise, then, that they are trying to take advantage of the recent Obama administration mishaps. So far, some Republicans, including Senate Minority Leader Mitch McConnell, R-Ky., have tried linking health care reform to the IRS scandal. He has suggested suspending implementation of the health care law until an investigation is completed into the Internal Revenue Service’s targeting of conservative groups.

Repeated requests by the Department of Health and Human Services for more money from Congress to implement the law have been denied. Congressional Republicans have started investigations to find out if HHS Secretary Kathleen Sebelius violated appropriations and ethics rules when she reportedly tried to raise funds for Enroll America, an organization that is helping to put the Affordable Care Act in place.

The states: Where the real action Is

But the real action on health care reform – versus the public relations battle – remains at the state level. An interesting red state-blue state divide has surfaced in which the availability of health care is being determined largely by the same political divide that settled the last two presidential elections.

According to an analysis by the Fiscal Times newspaper, the historic 5-4 ruling last June by the U.S. Supreme Court, which upheld the Affordable Care Act in the face of bitter opposition from conservative groups and Republican state officials, has become the key decision in how states will implement the law.

At the time, the Supreme Court voted 7-2 agreeing that Congress exceeded its constitutional authority by coercing states into participating in the Medicaid expansion or risk losing huge federal payments.

So far, 20 states and the District of Columbia agreed to expand Medicaid coverage – at virtually no cost to them during the first three years. Some 14 states have rejected the idea and another 12 states are leaning against it.

Remembering the red-state, blue-state election maps, tens of millions of poor or disabled people including millions of seniors, currently living on the eastern seaboard or in parts of the Midwest or along the Pacific coast will be in line to obtain Medicaid health care coverage for the first time next year. But millions more – living primarily in the south and southwest and portions of the Midwest – will be denied coverage because of political and budgetary calculations by their state political leaders and lawmakers.

To be clear, many low-income people locked out of state Medicaid expansion can still qualify for government-subsidized insurance under the new health care law. In states that have rejected the Medicaid expansion, low-income people earning between 100 percent and 138 percent of the poverty level have the option of turning to the insurance exchanges for subsidized insurance coverage. But the poorest of the poor with earnings below the federal poverty level would be out of luck – unless, of course, they decided to move to another state with the expanded coverage.

The Affordable Care Act made no provision for granting subsidies to uninsured people below the poverty level because the administration and Congress assumed they would automatically go into the Medicaid system. That, however, was before the Supreme Court ruling.

A new study from the non-profit Rand Corporation forecasts that 4.4 million people will be denied Medicaid insurance in the 14 states refusing to take part. That number will rise as the remaining 12 states make their decisions.

Some governors who were ardent opponents of the Medicaid expansion and had even joined the lawsuit that resulted in the Supreme Court ruling are now battling their own state legislatures trying to win approval of the expansion – because the amounts of money being given from the federal government to the states are staggering.

Arizona Gov. Jan Brewer has become an unlikely warrior for Obamacare. Brewer is a conservative Republican who sued to topple the health law, refused to set up a health insurance exchange and memorably wagged her finger at President Barack Obama on a Phoenix airport tarmac. But now she’s so determined to put the Obamacare Medicaid expansion in place in her state that she’s vetoing any legislation that reaches her desk until the Republican legislature caves.

Governors John Kasich of Ohio and Rick Snyder of Michigan are also locked in bruising battles to persuade state lawmakers to go along with the program. Florida Republican Gov. Rick Scott, an ardent critic of Obamacare, changed directions and endorsed the Medicaid extension, but his efforts have been blocked by the GOP-controlled state legislature.

When Texas Republican Governor Rick Perry said he would reject the Medicaid expansion, he contended the decision was for budgetary reasons. “It would benefit no one in our state to see their taxes skyrocket and our economy crushed as our budget crumbled under the weight of oppressive Medicaid costs,” he said. The new RAND report, however, concluded that Texas and the 13 other states that have rejected Medicaid expansion will forgo about $8.4 billion a year in federal funding and have to spend an extra $1 billion in uncompensated care – all while ending up with about 3.6 million fewer insured residents.

The big fear, as the Fiscal Times pointed out, is a “have and have-not” situation. G. William Hoagland, a senior vice president at the Bipartisan Policy Center, who ran the Senate Budget Committee for many years and is also a former health care industry executive, warns that with so many states refusing to take the offer, “You’re going to start to have a two-tiered system out there . . . and it sets up what I think will be further disparities in some states.”

Those states saying no include Idaho and Alaska; the southern states of Alabama, Georgia, North Carolina, South Carolina, Mississippi and Virginia; and the Midwestern and Southwestern states of Wisconsin, Iowa, Indiana, Texas, Oklahoma and Nebraska, according to Avalere Health, a consulting firm. All but Iowa, Wisconsin and Virginia supported Romney last November. Meanwhile, governors or state legislatures in seven other red states – Montana, Wyoming, South Dakota, Kansas, Missouri, Louisiana and Utah – are thought to be leaning against Medicaid expansion.

Finally, one projection of costs is giving the Obama Administration a positive public relations message to spin – that implementing the health law will cost consumers less money than current health care coverage. In California, one of the states that has set up its own insurance exchange as required by the Affordable Care Act, estimates are coming in as much as half the price of what was initially expected.

While these are only estimates, California officials finds an average of $304 a month for the cheapest silver-level plan in the state’s exchange next year.

Also contributing to this story: The Fiscal Times, CNN, Politico, the New York Times, Bloomberg and Kaiser Health News.

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