Washington – Less than a week before the opening of state insurance exchanges nationwide, no one is sure how this key element of the Affordable Care Act is going to roll out.
The Obama administration is hoping for a seamless debut. But even Obamacare’s biggest boosters predict there will be problems, though there’s debate as to how serious those problems will be.
“I am confident there will be glitches,” said Kevin Counihan, CEO of Access Health CT, Connecticut’s health exchange.
The biggest problem the Affordable Care Act faces next week may be technical.
The Affordable Care Act is supported by a matrix of computer technology in Washington that provides the state exchanges with a flood of information about each insurance applicant, including his or her income.
This “data hub “ also is supposed to allow states to check with the Department of Homeland Security to ensure that applicants are citizens or legal residents. It also is to tap an employer database to make sure that applicants are not already being offered affordable coverage by their employers.
The hub is also expected to determine whether an applicant is eligible for a tax break to help pay for an insurance policy.
But the hub providing all of this information may not be operational by Oct. 1, the day the exchanges open.
To prepare for that possibility, the federal government has waived for one year the requirement that states verify the income of those applying for health insurance subsidies.
The exchanges are meant to help people who are uninsured or underinsured. If Americans have adequate and affordable health benefits through an employer or coverage from a government health plan like Medicare or Medicaid, they may not shop in the exchange.
Obamacare defines “affordable coverage” as 9.5 percent of a person's income or less.
In Connecticut, Counihan said he is ready with an alternative if the federal computer system lets him down. Access Health CT plans to use the state’s Medicaid system to determine eligibility for federal tax breaks. Without the federal hub, it will be impossible for state officials to determine whether an applicant is reporting income accurately.
“We’ll assume that people are telling the truth,” Counihan said.
Connecticut’s “self –attestation “ program would require applicants to complete their application online, and follow up by providing copies of information such as W2’s or other documents by fax or paper to confirm information which would have otherwise been verified electronically via the hub.
Access Health CT says it has “vendors already aligned, and processes tested to resort to this system should a prolonged hub outage occur.”
Counihan is also worried about sabotage to the hub or the Access Health CT web site by the Affordable Care Act’s foes.
“There could be hackers from the tea party,” he said. “We’ve already had hackers from China trying to get in.”
Another potential problem: the states' exchanges are scheduled to open the day after the federal government may shut down. Ironically, Congress’ fight over defunding Obamacare has so far prevented it from approving a short-term spending bill that would keep the federal government running after Sept. 30, the end of the federal fiscal year.
Obamacare may be one of the few programs still functioning if there’s a government shutdown, because most of the ACA is funded through mandatory spending that won’t be affected by Congress’ inaction.
Counihan said is not concerned about Washington’s budget mess. He believes the state will be able to continue to draw down grant money needed to operate Access Health CT from the Department of Health and Human services. He also thinks enough HHS employees will stay on the job as “essential employees” to help state exchanges open for business.
In any case, the state and Obama administration have some time -- until Jan.l 1 -- to sort out problems before insurance policies in the exchanges begin offering coverage. And unisured Americans can sign up for coverage until April 1 before they face a fine.
Counihan, however, said it could take years for Obamacare to run smoothly, even as the public will make its judgment of the Affordable Care Act within the first few weeks or months after the opening of the exchanges.
“Look at the glitches that happened with Medicare, Part D,” he said.
Counihan is referring to the bumpy rollout of a voluntary prescription drug program for Medicare patients in 2006. There were computer breakdowns and seniors waiting endlessly on the phone to sign up.
There was also vast confusion about the plan, whether it was voluntary or not, and what it would cover.
Kevin Lucia, project director at Georgetown University's Health Policy Institute, also compares the opening of insurance exchanges to the implementation of Medicare, Part D.
“I think whenever you have a huge rollout of a government program that involves an IT system, you can expect problems,” Lucia said. “But states that have infrastructure in place will solve those problems quickly.”
There could be yet another problem.
Many of the uninsured in Connecticut who will receive health coverage through the ACA will do so because of the law’s expansion of the Medicaid program. Connecticut will expand Medicaid eligibility to those 19 to- 65 whose income is no more than 138 percent of the federal poverty level, or $15,856 per year.
New applicants will be able to apply through the Access Health CT web site, by mailing in paper applications or by phone.
But health care advocates worry the process will be cumbersome and lengthy. They are also concerned applicants will find it difficult to meet the ACA’s requirement that they submit proof of income, Connecticut residency and citizenship or legal immigrant status.
“They are making it harder to get in to Medicaid and I don’t think that was the intention of the Affordable Care Act,” said Ellen Andrews, executive director of the Connecticut Health Policy Project, a nonprofit dedicated to improving access to health care.
Andrews said it will be difficult for everyone shopping for insurance in Connecticut’s exchange. There will be inaccurate information about policies and what they cover, it’s going to be time consuming to apply through the Access Health CT portal and, for some people, required documentation is going be difficult to gather.
“Bumpy is an understatement, but it’s worth the hassle,” Andrews said. “Getting insurance is good for your health and your finances.”
The biggest test of the exchanges, however, will be if they succeed in signing up large numbers of uninsured, especially enough healthy, young applicants who will help keep the cost of insurance down for others.