Washington — As the clock ticks toward implementation of the most important elements of the Affordable Care Act, its congressional opponents are making a last stand to derail the law. Other problems loom as well, even in states like Connecticut, that are eager to implement the law.

The situation leaves the future health of Obamacare, as the ACA is commonly called, uncertain.

Implementation of the law could result in a patchwork, where it works well in some states, but fails to cover a substantial number of uninsured or keep insurance rates down in others.

“I think it’s somewhat hard to say” what the future will look like, said Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation. “I think the expectation is that states that are supportive [of the ACA] and have more people on the ground (to help implement it) … will have better enrollment.”

The next few months will help determine if Obamacare meets President Obama‘s goal of covering 7 million uninsured people by the end of March 2014 and makes health care coverage affordable for most Americans.

In Connecticut, the ACA is expected to experience some growing pains. But things are far more uncertain for the health care law in more than half the nation, where Republican governors oppose its implementation.

Twenty-six states have refused to establish state marketplaces, or “exchanges,” that would help uninsured and underinsured people buy coverage. In those states the federal government is setting up the exchanges, and, in many cases, is struggling to do so.

Some states have opted out of the ACA’s planned expansion of Medicaid that would extend coverage to more low income people -– even though they have sizable numbers of uninsured poor and the federal government would pick up all  costs for the first few years and most of the costs after that.

Obamacare requires that most uninsured people obtain coverage — either through their jobs, an agent or an exchange by April 1or pay a tax. But Americans can start using the exchanges Jan. 1 and begin shopping for policies on Oct. 1. Many participants will qualify for federal subsidies to help pay for their insurance.

Obamacare opponents in Congress are making a last stand, insisting that defunding of the law be part of a budget deal or an agreement to raise the debt ceiling. That means they are daring lawmakers to risk a government shutdown or national default to protect the ACA, a tactic that’s not expected to work.

While it is under attack in Washington, the ACA is much more vulnerable in the states, the new law’s testing ground. Few are willing to predict how it will roll out.

Even its leading proponents, including Kevin Counihan, executive director of Access Health CT, the state’s insurance exchange, talk of “glitches” and “bumps in the road.”

Counihan says that whether the law reaches its goal in other states is not going to affect its performance in Connecticut. “You can call something a failure, but it’s a law,” he said.

One such “glitch” in the implementation of health care reform in Connecticut could lie in the enrollment of low-income people in the state’s expanded Medicaid program.

Ellen Andrews, executive director of the Connecticut Health Policy Project, a nonprofit dedicated to improving access to health care, predicted “mass confusion and mass screw-ups” because new enrollees must now show tax forms and other documents and undergo a sign-up process that takes more than an hour.

“Most people won’t be able to do this on their own,” she said.

3 bellwether states

Three states could have a leading role in the success — or failure — of Obamacare.

California, Florida and Texas are home to more than one-third of the nation’s 46 million uninsured people. (Connecticut accounts for a fraction, about 300,000, of the nation’s uninsured.)

Yet the Republican governors of Florida and Texas are fiercely opposed to the ACA and refuse to help with its implementation.

Which leaves California.

With 6 million uninsured residents and a supportive Democratic governor, California provides the Obama administration with a great opportunity to showcase the ACA.

“If you are successful in enrolling people in California, it will go a long way in reaching the (administration’s) goal,“ Tolbert said.

While Connecticut has received about $114 million from the U.S. Department of Health and Human Services to establish its exchange and persuade people to use it, California has received more than $700 million to do the same.

California is spending so much of its federal funds on outreach that it is paying specially trained “enrollment councilors” $58 for each person they sign up on its exchange.

In addition, California has received a big slice of the $150 million HHS made available last month to help state health care centers enroll the uninsured. California received more than $22 million to hire 411 people who will try to enroll nearly 600,000 uninsured.

Connecticut received $1.6 million to hire 28 workers who would enroll about 23,000 state residents.

Getting out the message

Outreach is key to the successful implementation of the ACA — a recent Kaiser Family Foundation poll found that 43 percent of uninsured Americans have heard nothing about the new health insurance marketplaces.

But signing up the uninsured will be very difficult in some states.

Florida Gov. Rick Scott, a Republican, decided his should be among the 26 states that leaving it to the federal government to set up an online exchange. Unlike in California and Connecticut, rates that will be offered by Florida’s exchange are still under review by its insurance department and have not been made public.

And Florida’s Department of Health, citing “privacy concerns,” has barred anyone at county health centers from soliciting the uninsured.

Since the governors who oppose Obamacare won’t do any outreach, HHS has awarded grants to nonprofits and other groups to work as “navigators” or “assisters” in signing up uninsured people.

In Florida, 37 organizations received outreach grants.

Tolbert, from the Kaiser foundation, said the political fallout of deliberate attempts by GOP governors to sabotage Obamacare “is a difficult question.”

“When it comes down to the issue of who is perceived to be at fault, some may blame the ACA,” Tolbert said. “But people in Texas may blame the state when they can’t get coverage because their governor did not expand Medicaid. The ACA as a whole may not be perceived as having been a failure.”

Counihan said the law will take years to be fully implemented and any talk of weighing its success or failure should wait until then.

But he said there’s a good chance Congress will have to eventually modify or “tweak” the law to address shortcomings.

The ACA will be scrutinized on whether it hits enrollment goals. But perhaps even more on whether health insurance premiums are affordable.

The ACA’s requirement that all Americans receive a certain level of coverage will push up premiums, as will  caps on out-of-pocket health expenses, elimination of bans on pre-existing conditions and other discriminatory practices. Those forces could outpace factors that would depress premiums, especially the new purchase of insurance by many young, healthy Americans who will be forced to obtain coverage under the law.

“There are a lot of unknowns,” Tolbert said. “There’s been a lot of concern about rate shock.”

But Tolbert said rates haven’t risen as much as had been expected. She also pointed out that the cost of health insurance would have risen with or without the ACA becasue they were rising before the law was approved.

Tolbert agreed with Counihan in that it could take years for the ACA to operate as it was intended and revisions are certain to be made. But she doesn’t think a repeal of the ACA is in the offing, even if it’s national roll-out is rough.

“There will be glitches,” Tolbert said. “And maybe not next year or the year after that, but eventually Congress will be in a better position to make some changes.”

Ana has written about politics and policy in Washington, D.C.. for Gannett, Thompson Reuters and UPI. She was a special correspondent for the Miami Herald, and a regular contributor to The New York TImes, Advertising Age and several other publications. She has also worked in broadcast journalism, for CNN and several local NPR stations. She is a graduate of the University of Maryland School of Journalism.

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