Robert I. Field, Ph.D., J.D., M.P.H.
The voters have spoken, and Obamacare no longer faces the prospect of repeal on day one of a Romney administration. The election removed the last direct threat to its implementation.
Does that mean it is now full speed ahead? Maybe not. Several impediments could still stand in the way.
The first and most important is the gargantuan task of putting the many pieces of the law into effect. The insurance exchanges that will sell policies to individuals are slated to begin operating next October 1 – just over ten months from now. There’s much to be done before then. For starters, websites must be created through which customers will do their shopping. Software has to be developed to run the sites. Insurance plans have to be devised to be sold on them. And the public has to be told how to use them.
Medicaid is set to cover millions more people starting on January 1, 2014. Before that can happen, states must expand their administrative infrastructures to handle the higher volume of enrollees and claims.
The Obama administration will soon begin issuing new regulations to guide the implementation effort. However, these are just a start. More direction will be needed before the law’s many complex provisions can take effect.
Political hurdles also remain. Republicans in Congress do not have the clout to repeal the law or to pass significant amendments, but they could still try to block funding. Cuts for implementation could pose major problems for an effort that is so massive and has such a tight timeframe.
Funding for Obamacare will also have to survive negations between the parties on averting the “fiscal cliff.” That is the treat of large across-the-board budget cuts next January if an agreement on deficit reduction is not reached. If those cuts take effect, they could knock out needed funds. And Republicans could demand cuts or delays in implementation as part of the price for a deal.
And the heated emotional controversy over insurance coverage for contraception continues. The administration has yet to issue a final rule on which employers will have to offer policies that include it. Some religiously affiliated organizations assert that doing so contradicts their beliefs. The controversy could stir new opposition to the law.
Several new legal challenges have also begun to wend their way through the courts. However, it is unlikely that the plaintiffs could convince the Supreme Court to consider the law again.
The biggest wildcard is the role of the states. Each has to make two big decisions. One is whether to establish its own insurance exchange or let the federal government do it instead. The other is whether to expand its Medicaid program as the law envisions.
Ten states have so far declared that they will not set up exchanges, and 24 have yet to decide. If the federal government has to run most of them, it will face a huge logical challenge.
Six states have so far declared that they will not expand Medicaid, and 22 have yet to declare. If many of them decline to do so, it would leave a huge hole in the Obamacare safety net.
Those decisions may change during the months ahead. Most of the states that have refused to go along with Obamacare have Republican governors. With the election settled, they may find little political mileage in continuing to hold out. And their health care providers may push hard for implementation of the law, which will bring them many new paying customers. However, those decisions are yet to be made.
The story of Obamacare continues to follow twists and turns. Obama has overcome many challenges to it, and his dedication is likely to bring health reform across the finish line. But even with the election over, it is not there yet.
For more perspectives on the issue, a panel of local experts will consider health reform after the election, with a focus on implications for the Philadelphia area, at the Academy of Natural Sciences of Drexel University on Friday, November 16. Information is available here.