Top Five Implementation Problems with the Affordable Care Act

Questions about Obamacare dog law as it moves toward full implementation

July 16, 2013

Key parts of Obamacare have been delayed recently due to the administration’s failure to implement the law in time for its scheduled rollout. These delays raise questions about the healthcare overhaul viability in the eyes of congressional critics and some healthcare experts. Here are the top five remaining questions about the law and its impact.

1. Will the technology work?


Undergirding the law is a matrix of technology that integrates various parts of the public and private sector and provides the exchanges real time access to individuals’ income.

The federal government waived for one year the requirement that the states verify the income of those applying for health insurance subsidies. This delay suggests that the "data hub" containing all of this information will not be ready by the Oct. 1 deadline.

However, the law also requires other technology that allows people to sign up for private insurance through the state exchanges, requiring a smooth integration between the private entities and the government.

"The real question for the insurer is, am I going to get accurate data?" said Ed Haislmaier, a health policy expert at the Heritage Foundation.

The insurers will want to be sure that they know whom they are insuring and that they will get paid, Haislmaier said.

James Capretta, a fellow at the Ethics and Public Policy Center, said the technology implementation means the insurers and the government’s systems could integrate in a clunky and inefficient way.

2. Will the individual mandate be enforceable?


The delay of the employer mandate—which requires that employers over a certain size give their employees insurance—raises the question of whether the individual mandate will be enforceable, said Capretta.

"You have a system now where the employers and insurers no longer have to report information to the IRS," he said.

This information gap means that the government will have fewer tools at its disposal to verify independently if somebody actually has insurance.

The result, Capretta said, is that only people who self-report as not having insurance will pay the penalty—a system that penalizes honesty.

"I think it exacerbates some of the problems of having a social welfare policy run through the tax system," Capretta said.

3. Will the exchanges be viable?


If too few healthy people sign up for insurance through the state-based insurance exchanges, the insurance pool could be too small and those needing to draw on their insurance plans could overburden the insurance companies, driving up costs or causing insurance companies to withdraw from the exchanges.

"That’s what the administration is really worried about," Haislmaier said. "There’s very much the possibility that it becomes a super-risk, high-risk pool."

The exchanges’ woes are compounded by the fact that the majority of states have declined to run their own exchanges, forcing the federal government to step in even though they do not have the requisite manpower on the ground, Capretta said.

"It’s going to be a challenge," Capretta said.

The Department of Health and Human Services has reportedly been in talks with professional sports leagues and other celebrities to gain their support in encouraging younger people to enroll through the exchanges.

4. Who will be offering plans through the exchanges?


The public will not know who will be offering what kinds of plans through the federal exchanges until September, raising the question of the number of choices people will actually have.

"From the general public perspective, we have no idea how many carriers and plans will be in there," Haislmaier said.

The regulatory burdens that the law imposes on businesses will probably force out smaller firms for whom health insurance is a secondary line of business, he predicted.

But the exchanges could further exacerbate the problem in states that already have limited choices, Haislmaier argued.

States like California have a relatively diverse and competitive health insurance market, a situation that will persist within the exchanges, he said. But smaller states with a less diverse market could see it shrink yet more under the exchanges.

5. How will Obamacare’s implementation affect the midterm elections?


The employer mandate delay gives businesses another year to make a decision about how to handle health insurance under the new regime—and they will likely be making their decisions in the months leading up to the election, Haislmaier said.

If businesses start making decisions that hurt their employees because of Obamacare, the law’s reputation could be harmed—and with it Democrats’ electoral hopes.

A clunky rollout, nearly complete by that time, could further hurt the Democrats’ reputation, Capretta said.

Both parties have incentives to nationalize elections, said Kyle Kondik, communications director for the Center for Politics at the University of Virginia.

However, both he and Capretta were unsure whether Obamacare would be a big factor come November.

"Whether the national environment is right for people to be mad about it, I just don’t know," Kondik said.