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The Swing States of Obamacare

August 22, 2013
Politico
Jennifer Haberkorn

Three states could have an outsize 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. If the White House and its allies can’t convince large chunks of the uninsured in those three states to enroll in the Affordable Care Act’s new insurance exchanges, the administration could have a very hard time reaching its enrollment goals.

“They have set out 7 million as their goal for enrollment in the first year and politically, getting close to 7 million is important,” said Caroline Pearson, vice president at Avalere Health. The enrollment period starts Oct. 1 and runs through March.

If Obamacare were a presidential race, these would be the “swing states.” Instead of a trove of voters, they’ve got millions of uninsured, and they’ll get high-profile administration visits, money, resources and loads of national press attention. And many of those uninsured are the “young invincibles” — the young healthy people who need to be brought into the new insurance markets to balance out the older and sicker customers.

“You look at the big states because that’s where the large numbers are,” said Joel Ario, former director of HHS’s office of insurance exchanges and now a managing director at Manatt Health Solutions.

President Barack Obama, Health and Human Services Secretary Kathleen Sebelius and outside groups such as Enroll America are already dedicating time and resources to playing big in Texas and Florida — the two states with the largest uninsured population and resistance from the local Republican-led governments.

Obama also gave one of his rare health care speeches on a June visit to California, which is the only one of the big three to embrace the health law and put significant money and energy of its own into outreach.

But just like in an election, there’s more than one way to do the math. These three “swing” states could have an outsize impact, but the White House and its allies are also putting energy into a second tier of high-impact states that have lots of uninsured people — and in most cases GOP governors who to varying degrees oppose the president’s health law. They include Arizona, Michigan, North Carolina, Ohio, New Jersey, Pennsylvania, Georgia and Illinois.

Enroll America, the nonprofit with close ties to the former Obama campaign operation, has hired staff to run a ground game on enrollment in these states, plus Florida and Texas. In most of them, the states refused to set up the exchanges or marketplaces — the online portals where people can sign up for insurance and qualify for tax subsidies — so the federal government had to step in.

CALIFORNIA

In California, which has more uninsured residents than any other state, the local government is doing the heavy lifting on Obamacare enrollment, supplemented by what’s expected to be occasional visits by the White House, like that June visit by Obama to tout California’s early success in carrying out the law.

The state government has already provided a staggering $43 million for enrollment outreach alone. The state’s exchange authority has gotten money to pay enrollers $58 for each successful application. And California began holding town hall events and other outreach on the ACA well before most other states.

Here, the law — and the president — is so popular among the uninsured that they train volunteers to call it Obamacare. In most other states, volunteers are taught to use less politically charged terms.

Because of the money and resources, California is frequently touted as the state that is implementing the Affordable Care Act most actively and aggressively. The stakes couldn’t be higher.

“The ACA can’t succeed if California fails,” said Drew Altman, president of the California-based Kaiser Family Foundation. “But it’s not the whole story,” he said. California needs to have a fully functional exchange, he said, but so do middle-of-the-country states.

TEXAS

Texas’s significant uninsured population — 5.8 million uninsured and 2.3 million young uninsured — means the Obama administration has to play hardball here. Top HHS officials have already been here — and they’ll be back.

Sebelius was in Austin and San Antonio in early August to hold events with health care industry executives and the mayors of both cities. Earlier, she held health events in Dallas and Forth Worth.

Marilyn Tavenner, who as the administrator of CMS is overseeing the creation of the exchanges, told a congressional committee earlier this month that she will be traveling to Texas often.

That attention will be supplemented by “navigators” — federally funded guides to the signup process. Eight Texas groups on Thursday received nearly $10.9 million to spend on navigators — more than any other state.

“Texas is a huge population with a huge number of people who can [benefit] from the Affordable Care Act,” Tavenner said. The navigator grants mean “there will be a lot of people on the ground in Texas helping folks get signed up.”

It won’t be easy. Gov. Rick Perry has resisted the law vehemently. The law is largely unpopular in the Lone Star State, but many of its proponents say that’s because of the massive amounts of misinformation.

“We’re at the point where we need big billboards that say: ‘There is money for you to get health insurance,’” said Bee Moorhead, executive director of Texas Impact, a statewide religious grass-roots network that’s trying to get word out that many people will be able to get subsidized coverage.

FLORIDA

Enroll America, the nonprofit group that is spreading word about the law, is putting significant resources in Texas, Florida and eight other states with large numbers of uninsured people.

The group already has 27 staffers on the ground in the Sunshine State, with plans to hold information sessions, knock on doors in neighborhoods with high concentrations of the uninsured and set up tables at community gatherings.

“This August is children and families month, as we’ve branded it,” said Nick Duran, Enroll America’s Florida state director. “We’ll be present at back-to-school events … and community colleges.”

Enroll America’s president, Anne Filipic, said the group decided to put its own resources in the states with the highest uninsured residents — with the exception of California and New York, where state governments are devoting enormous resources to enrollment.

“It ended up being a really simple thing: looking at where do the uninsured live … and also looking through the lens of what resources are already going into the state,” Filipic told POLITICO.

Florida received a relatively large $7.9 million navigator grant.

In Florida, the state decided not to run the exchange, but so far it hasn’t signaled that it will actively thwart it either. Gov. Rick Scott wanted to expand Medicaid under the health law, but the state Legislature did not approve it. Some of the Florida insurers are also competing for exchange business so they’re likely to do a lot of advertising of the exchanges — and because there are a lot of insurers in the state, they may compete on price.

“If you look at those large states, they do tend to have pretty competitive insurance markets,” Ario said. That, he says, will help keep rates low and potentially bring in some of those uninsured customers.

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