Is Obamacare’s greatest challenge its namesake?

EDITOR’S NOTE: Healthinsurance.org’s Curbside Consult is a periodic informal dialogue with medical and health policy experts about pressing issues of the day.

Larry Levitt is one of the nation’s leading experts on health reform. He is Senior Vice President of the Kaiser Family Foundation, where he heads the foundation’s program that tracks implementation of the Affordable Care Act. We caught up just after election day to discuss how Republican victories might change the on-the-ground realities of health reform.

Below is a transcript of our conversation. It’s been edited to make the translation between spoken and written English.

Transcript of Part 1 (of 3):

Harold Pollack: Maybe we should start with you … if you can give us your name, rank and serial number to start. Tell me what’s your role in this healthcare world.

Larry Levitt: I’m senior vice president of the Kaiser Family Foundation and I head our program tracking implementation of the ACA and the insurance market changes. The Kaiser Family Foundation has nothing to do with Kaiser Permanente or Kaiser Aluminum or Kaiser Cheese. We’re, I think, a fairly unusual health policy organization in that we don’t take positions, we don’t advocate. Our role is information and that spans everything from policy analysis that I do looking at the implications of changes in the ACA and other health policies to news. We have an in-house news operation – Kaiser Health News – that writes stories and makes us available to other news organizations.

We basically define our role as information. We’re about informing and hopefully making debates better and more informed and hopefully that results in better decisions which sometimes it does and sometimes it doesn’t.

Harold Pollack: Congratulations on the Mississippi story among other things that just appeared in Politico Magazine.

Larry Levitt: Oh yeah. It came terrific.

Harold Pollack: Such a tragic story … just a heartbreaker.

Larry Levitt: As with a lot of the ACA, a lot of things haven’t quite gone as we expected.

Harold Pollack: That was a really dark-end-of-the-spectrum story in just about every way. Everything you’d be worried about seemed to come to pass there.

Larry Levitt: I know it’s complicated too. You had leadership in Mississippi that had actually wanted to be involved, wanted to create an exchange but larger politics certainly got in the way.

The politics of ACA

Harold Pollack: It seems like there’s interest group politics of ACA and there’s partisan politics of ACA. And I think a lot of us – and I’ll put myself in this category – who were supporters of ACA were over-optimistic that the interest group politics would dominate the partisan politics quickly. And they may eventually dominate the partisan politics, but it’s certainly been a tougher fight than many of us expected.

Larry Levitt: I would agree. I think many people underestimated how partisan and ideological this would end up being. The President’s a divisive figure and the law has his name on it: Obamacare. That has driven a lot of people’s perceptions.

Public perception really hasn’t changed much from the very start. It ebbs and flows but public perception of this law is driven mostly by public perception of the President.

How is ACA going?

Harold Pollack: I thought we would do two things in the conversation: 1) is we can talk a little bit about how the ACA’s going independent of the election and 2) how do you think the election is going to affect ACA’s implementation and things we might look out for? Leaving aside the election, how do you think ACA’s implementation is going at the moment?

Larry Levitt: A the moment, I would say actually pretty well. I don’t think anyone expected this to be perfect. You know as well as anyone that any new program, particularly a program this large and this complicated is frankly, virtually unprecedented, takes time to ramp up. Most new programs don’t get implemented in as complicated and divisive a political environment as this one did.

But you know, these things take time. I remember way back, right out of graduate school I was working for the State of Massachusetts. We were starting up Massachusetts Health Reform 1.0, which was ultimately repealed. I headed that with my boss. I was doing budget projections and I had a bet with my boss about how long it would take us to reach our enrollment projections. I thought – eh, you know – within a year or two we’d be there and he told me I was crazy and naïve and he was right. These things just take time to ramp up.

The fact that signups in the marketplaces and Medicaid enrollment essentially were as expected if not better in the first year – I think you have to feel good about that. Certainly the website debacle of the first year was a setback. I’m sure with open enrollment this year it’s not going to be perfect but I think it’ll probably work as the President just said, “They double and triple checked.”

Now, I think they have to turn to actually not making it just work but making it work well. The website is not a – and I don’t think will be for open enrollment two – it’s not a model, online shopping experience yet. Hopefully it will get there.

Certainly the fact that half the country doesn’t have access to the Medicaid expansion is holding back the law. I think particularly with the recent election results it’s going to take awhile for that to change.

Harold Pollack: When you say half the country, 80 percent of the adults affected are in the Southeast.

Larry Levitt: Yes, absolutely. Not half the country geographically. [laughs] Certainly half the states have decided not to expand. I think there was some expectation if the election had gone differently that that might change, but it’s hard to imagine it changing in the near term.

Reaching the uninsured

Harold Pollack: How many people are insured today who would not have been insured if ACA didn’t exist?

Larry Levitt: We still don’t have a perfect answer to that question but I think we’ve got a pretty damn good answer to that question. If you look at all the private surveys that have been done from us, from the Commonwealth Fund, from Gallup, from Urban [Institute], and RAND – as well as some of the federal survey data that’s started to come out – I think it’s pretty clear that there are 8 to 10 million more people insured now than would have been insured if the ACA had not happened. That’s a big effect.

Harold Pollack: How much do you think that will go down over the next year or so? Is there any sort of forecast? How many people will remain uninsured in America?

Larry Levitt: Right – and we’re talking about tens of millions – roughly 30 million people still uninsured. Some of them are undocumented immigrants. That’s probably in the upwards of seven million who are not eligible for any of the programs under the ACA, and that’s not likely to change.

Some people just are never going to get connected to the system. In fact, as we go along, the people left are going to be harder to reach than the people we have already insured. I think it’ll ramp up substantially over the next year or two, and then it’s going to get really hard to make progress.

Harold Pollack: I research substance abuse policy issues and one of the things not happening is the states are really not investing a whole lot of money to go after these particularly vulnerable populations or to help the substance abuse treatment providers reach a lot of their neediest clients, who we know are the least knowledgeable people about health reform. They’re going to have the greatest number of barriers to getting signed up. There’s a big implementation challenge as we insure more and more people, the people left have more and more barriers to successfully engaging the health financing and healthcare system.

Larry Levitt: Certainly if you’re talking about substance users or people with mental illness, or people who are homeless, these are all people who are likely, in many cases, eligible for Medicaid in states that have expanded. But reaching them and connecting with them is hard.

Signs of progress or trouble

Harold Pollack: What should we be looking for over the next year as a sign that ACA is going well or a sign that we should be pretty concerned about how it’s going?

Larry Levitt: First order of business has to be the technical details – a working website, people able to apply without having their applications get kicked into some inconsistency category and be stuck in a warehouse in Kentucky and not be able to get on the program or be at risk for being kicked off. That’s the first thing, just making sure the basics work.

Then, you don’t want to focus only on the metric of sign-ups but ultimately the goal of this law is to get people insured. Sign-ups are the measure of that. It’s people signing up in the marketplaces and people signing up for Medicaid which they can do all year.

Ultimately it’s our way of making a bigger dent in the number of uninsured. To me, that has to be the ultimate measure of success.

Harold Pollack: When we get to tax day, will there be a whole set of glitches around people owing money that they didn’t expect to owe, not getting refunds they expected, etc.?

Larry Levitt: We know that there are going to be people who are going to reconcile their tax credits on Tax Day. The tax credits they’re getting in the marketplaces are just estimated, and those have to be reconciled when people file their taxes.

We know particularly for people in the income range that are getting these subsidies, they often live very chaotic lives and have a lot of volatility in their income. Their work hours may change from month to month. They may lose jobs and get jobs. A spouse may get hired or get fired. A lot of people are going to be reconciling their tax credits.

There will be positive surprises and negative surprises. Some people will get a refund that they didn’t expect. Other people are going to owe money that they didn’t expect. I think a lot of people are confused about that. We know people are confused about many elements of this law. I would suspect that a lot of people don’t know that this reconciliation is going to happen.

There are also a lot of mechanics that have to work for this all to happen well. People need to get forms from the marketplaces, from their employers to give them information to then file their tax returns. For many people in his income range, their tax returns are all of a sudden going to be a lot more complicated than they used to be. So I think there is a potential for glitches, potential for unhappiness and certainly potential for news stories focusing on these anecdotes.

Why is everything so complicated?

Harold Pollack: Is there a better way to do this so that it’s less complicated? Critics of the law say it’s a Rube Goldberg set up. This does seem like an exhibit in their favor … that this is just imposing a lot of complexity on people.

Larry Levitt: Yeah, I will say having drafted parts of the Clinton Health Plan, there were many times during that travesty that we turned to each other and thought, “Boy there’s got to be a simpler way of doing this.” The Affordable Care Act is probably not the simpler way.

It is in some ways a Rube Goldberg scheme, driven in large part by the fact that we want to maintain the employer-based system … so that introduces a lot of complication. The subsidies we’re providing people are through the tax system … so you’re talking about trying to mesh insurance with the tax system which leads to a lot of complications.

In many ways, Medicaid is much simpler here. Medicaid is based on your current circumstances; if you’re low-income now and you’re eligible for Medicaid you get on the program and you’re guaranteed a certain period of eligibility. There’s no reconciliation.

We could simplify this a lot by giving people eligibility for marketplace subsidies outside of the tax system based on their current income and not reconciling. We’re somewhat allergic in this country to giving people help that we think they may not ultimately deserve.

Harold Pollack: It’s ironic that the ideological constraints that we have that prevent us from making more open transfers dramatically put us in a situation that forces us to have a more complex way of helping people. And we’re really not huge fans of complexity either.

So we sort of put ourselves in a Catch-22 as a country where we really won’t accept anything except for something that’s kind of a very complicated setup that’s barnacled onto our existing setup … and we say, “Wow, this is really too complicated.”

Larry Levitt: Right, it’s not that we don’t know how to do this technically. Yeah, I think you’re right. It’s that our ideology gets in the way of simplicity.

Harold Pollack: Jim Marone has this wonderful book, The Democratic Wish, about a sort of wish to get rid of bureaucracy … and how we end up having to recreate bureaucracy as an effort to get rid of bureaucracy when this isn’t really possible.

In Part 2 of this interview, Pollack and Levitt talk about the implications of the 2014 elections for health reform and likely changes to the law; the fates of the employer and individual mandates; and how bi-partisanship could improve the law.

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Harold Pollack is the Helen Ross Professor at the School of Social Service Administration. He is also Co-Director of The University of Chicago Crime Lab. He has published widely at the interface between poverty policy and public health. Pollack serves as a Fellow at the MacLean Center for Clinical Ethics at the University of Chicago, and as an Adjunct Fellow at the Century Foundation.