On Oct. 1, the Affordable Care Act, aka Obamacare, crosses an important benchmark, as the state health insurance exchanges begin operating. These state insurance exchanges will function as open marketplaces where individuals can buy private health insurance under the act. The exchanges will centralize purchasing: Once a person fills out an application, he or she can see all of the plans available in that state as well as any subsidies or government programs for which they might qualify.
The Affordable Care Act is a complex law, to be sure. But three factors have made this important stage in the rollout of Obamacare especially treacherous.
First, the rollout is happening amid an opposition campaign that is unprecedented in its ferocity, relentlessness and disregard for facts and the common good. Republicans, led at this stage by Texas Sen. Ted Cruz, have become maniacal in their opposition to Obamacare to the point that they threaten to shut down the government and default on the national debt. Their opposition is beyond reasonable. Speaker John Boehner and other congressional veterans have warned Cruz and his tea party allies that shutting down the government is a very bad idea politically, but the tea partiers have long been immune to political common sense.
If people believe that the Affordable Care Act may be defunded, it is unlikely they will be motivated to find out about the exchanges, how they work and what opportunities -- and subsidies -- people without insurance now have to procure it. Moreover, the GOP continues to misrepresent provisions of the law in order to deter people from signing up, with the hope that the fewer people who take advantage of the health reform act, the more likely it will fail. Essentially, they are trying to scare the people who need it the most out of buying health care insurance.
Second, in their political blindness, some Republican governors have refused to set up state exchanges and others have refused to expand Medicaid within their states, even though the federal government will pay for 90 percent of the cost of the expansion (see story on Page 1). Taken together, these Republican governors have thrown a monkey wrench into the law. The expansion of Medicaid was designed to extend health insurance to the working poor, and those workers who should have been but won't be added to Medicaid rolls now face the risk of having nowhere to turn for health care insurance. Additionally, residents in states that have no exchange will go to a federally run exchange, again something the government was not ready to handle to the extent necessary. The drafters of the Affordable Care Act did not anticipate that 34 states would decline to set up their own exchanges, but that is what has happened.
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It is no wonder that, in turn, insurance companies have gotten skittish about participating in the exchanges. If insurance companies stay out of the exchanges or limit their participation, they put at risk the economies of scale needed to make the exchanges, and thus the whole system, work as expected.
Catholics bear a special burden in the ongoing disinformation campaign against Obamacare. Early in the debate, Catholics allowed a few conservative bishops and a few conservative political interests to seize the church's megaphone and they have never let it go. Even after wrestling from the administration exemptions and accommodations to contraceptive coverage -- coverage the vast majority of lay Catholics support -- the bishops are unable to call a victory in that battle and mobilize their people to support aspects of Obamacare that fit hand in glove with Catholic social teaching.
The third challenge facing the rollout of Obamacare is a self-created hurdle: The administration is not really ready to implement the law and has done a lousy job defending it. Knowing the stiff opposition the law has faced, the Department of Health and Human Services should have been better prepared for the administrative and technical glitches that bedevil any large program rollout. The department wasn't. There was no fallback plan to deal with the possibility that some states would not expand their Medicaid programs. The administration delayed the employer mandate for a year, but not the individual mandate; it gave a waiver to Congress for its health care plans, but not to labor unions. Some states, such as Oregon, that are not led by politically hostile opponents are still not ready to launch the exchanges because of confusing directives from Health and Human Services.
Perhaps most important, the law remains unpopular in large part because the administration has failed to consistently and persuasively make the moral argument for it. President Barack Obama is fond of saying that good policy is good politics, but that is not always the case, especially when you have said little about the law and its opponents have relentlessly mischaracterized and otherwise denounced it. Opponents have shaped the conversation. No wonder the American people are, at best, ambivalent about Obamacare. For example, why don't more people know about the June report from PricewaterhouseCoopers that rising health care costs are slowing at a rate that "defies historical post-recession patterns and is likely to be sustained"?
There is still time. This is a law that was duly passed by Congress, upheld by the Supreme Court and successfully defended in a presidential election. Now is the time for political leadership, not only policy expertise. Congressional Democrats, who ran from the issue in 2010, need to embrace it and speak about its benefits whenever and wherever possible. Obama should spend a week speaking about nothing but Obamacare, how it works, who it can help, why the nation will be better when it is implemented. In the absence of such efforts by the law's defenders, they will have no one but themselves to blame if the opposition continues to dominate the debate.
Certainly religious and civic groups should step up to the plate and help educate the public, especially the poor and working poor, about how the Affordable Care Act can work to improve their lives. Catholics in particular must put aside the issue of contraception and stump for this valuable social policy. Once people realize that their premiums really are not going up as fast as they were, once individuals previously unable to afford insurance can find it, and once the working poor receive just subsidies to purchase what is a basic human right, the implementation will go smoothly.