One overlooked impact of the staggeringly inept rollout of the Affordable Care Act is its effect on those who need help the most. The working poor, people of color and youth could make historic healthcare gains from a fully functional ACA. But the act's implementation effort, dominated by gaffes and incompetencies, adds to the difficulty of younger, poor Americans of color to find federally subsidized plans for which they are eligible, a need especially acute in the 25 states who've opted out of Medicaid expansion.
Disturbingly, the botched kickoff was highlighted yet again by several key administrative reversals just last week. Together these mistakes have put a question mark over the entire effort to provide 46 million Americans with vital health insurance. This initial rough crossing has led to many questions about the future trajectory of Obama's presidency. With so many twists and turns since the October 1 rollout, let's start with the latest crisis and work our way back over the past seven weeks to get a sense of how the ACA's mishandled launch has affected poor Americans in the states with policies most hostile to them.
Last week's problem
The sense of an ACA in trouble was heightened this past when the Republican-controlled House of Representatives--with the support out of one out of five Democrats--passed a bill to undo an important provision of the law. The Congressional vote came a day after the president did the same through an executive order. Their action was in response to the fact that five million Americans received notices from their insurance companies recently that their healthcare plans would effectively be cancelled at the end of the year. That's because these plans as, Bob Smero of the Bell Policy Center points out, did not either end lifetime caps on how much they would spend on patients who ended up in hospital, expand parental coverage for children up to age 26 or properly cap costs and premium hikes. But the fact that these plans are suboptimal isn't the key point.
The problem is that since 2009 President Obama told Americans that under the law "if you like your plan, you can keep your plan." Consequently, millions felt confused and caught off guard when cancellation letters started to arrive in the mail. The groundswell of public anger led Obama to retreat on this part of the law in order to allow these deficient plans to continue for one year. The House of Representatives including many Democrats want them extended indefinitely.
The bigger issue of healthcare.gov
But for close to 50 millions Americans without insurance, the biggest problem so far is that the primary vehicle that allows them to get coverage, healthcare.gov, basically doesn't work. Healthcare.gov provides healthcare plans for residents of the 27 states without their own state-based health insurance exchanges.
The numbers underscore the scale of this fundamental error. With a government estimate that 500,000 people would sign up for coverage during the first month of healthcare.gov, only 26,000 have managed to do so through the site. State-based changes have fared far better, signing up close to 90,000 Americans.
Despite the better state numbers, healthcare expert Timothy Jost of Washington and Lee University told NBC News, "A disaster of this scope I don't think anybody expected. What the numbers tell is that the technology is not working."
How did healthcare.gov end up on its back?
The bottom line is that the lack of a single person responsible for overseeing its construction, the selection of dodgy private contractors to build it, and the use of faulty code have led to a site that 1) can't handle a large capacity of users, 2) finds it difficult to communicate across different government servers required to complete applications, and is 3) just plain dysfunctional. Of course the 42 votes against the ACA by the the House of Representatives and a Supreme Court challenge of the law did not help administrative focus on the project.
Though both President Obama and Secretary of Health and Human Services, Kathleen Sebelius, have offered apologies for the site and pledged to have it largely fixed by November 30, government officials responsible for doing so have cast doubt on their ability to turn it around by that date. True, President Obama has accurately stated that the ACA, "is not just a website" but technology failures in the information age have real-world consequences including for the most vulnerable.
Technology's fail and the poor
Given that half the states have failed to expand Medicaid, healthcare.gov is essentially the only coverage on-ramp for many of the of the six out 10 Americans eligible for the enlarged program but who are prevented from accessing it. Medicaid is the joint federal and state program to provide health insurance to the working poor and their children.
The Kaiser Family Foundation estimates that three million of the eight million Americans who are Medicaid eligible but who live in states resistant to the program will be eligible for subsidies and help through healthcare.gov. But as long as the website is down, these Americans will continue to be outside of the healthcare system.
The issue of a functioning healthcare.gov is vital for people of color. As I have written before, the issue is that the vast majority of Southern states--where half of all blacks in the U.S. reside and home to Texas, with the second largest population of Latinos in the country--have opted out of the Medicaid expansion. But through a functioning healthcare.gov this "coverage gap" can be lessened, though not erased.
Though President Obama has said that Americans can also sign up by phone or in person for, applications can only be completed by ultimately passing through the computer systems currently gumming up healthcare.gov.
To be clear, Medicaid expansion in states where it is taking place is working far better than the healthcare exchanges. Four times more Americans have managed to get insured through Medicaid than either the state or federal healthcare websites. But only through functioning technology at the federal level can millions more of working poor Americans unable to get Medicaid receive coverage.
The difficulty here is that a key pillar of the ACA is broken with important consequences for the historically marginalized but it could have even broader implications as well.
The disorder surrounding the ACA led The New York Times in an article to speculate whether the law's rocky takeoff is President Obama's "Hurricane Katrina." The confused response to that deadly hurricane is often cited as the beginning of the end of the Bush Presidency in the minds of the public that had elected him only a year earlier. But the comparison of the ACA to Katrina is clearly a hyperbolic stretch. One event killed over a thousand Americans while the point of the other is to save lives.
If the ACA's problem's are straightened out over the next few months, these early difficulties and negative comparisons will clearly fade away. But the fact that the question was posed at all is potentially worrying. They may be a sign that the ACA may endure more tough times before things get better.