Addressing healthcare

President Barack Obama rarely makes much mention of healthcare in his annual keynote speeches, but this week he could use the forum to help launch a historic enrollment effort.

The relatively few healthcare references in the president's four previous State of the Union addresses came despite healthcare reform as Obama's leading domestic policy goal and then signature legislative achievement.

That could change, said health policy experts, with the final address before the coverage expansion authorized by the Patient Protection and Affordable Care Act launches later this year. Informing an estimated 27 million of the nation's 58 million uninsured citizens that they are newly eligible for some type of insurance coverage is seen as one of the Obama administration's biggest challenges in 2013.

“That's just a herculean task that we have been preparing for since basically the legislation was passed and signed into law,” said David Lemmon, communications director for the liberal consumer advocacy group Families USA.

His group and others have launched educational campaigns sometimes in tandem with growing enrollment efforts by the Obama administration. Those efforts are needed, policy experts said, because if younger, healthier enrollees do not sign up, then costs of the new coverage system will fall on older, sicker Americans.

Families USA Executive Director Ron Pollack is leading one such group, Enroll America, which he said will spend “tens of millions of dollars” this year on a publicity campaign aimed at more than three-quarters of the uninsured who do not know they are eligible for coverage. That group's board of directors includes many leaders of the healthcare sector's biggest groups, including Sister Carol Keehan, president and CEO of the Catholic Health Association, and Richard Umbdenstock, president and CEO of the American Hospital Association.

“Enroll America is going to play a strong leadership role and will work closely with a very substantial number of organizations and with the public sector, including with the administration and states,” Pollack said in an interview.

The administration's second major healthcare task this year is implementation of the complex coverage systems to which it is driving new enrollees. Officials face daunting logistical challenges as they attempt to execute a historic Medicaid expansion by 2014 and create functional health insurance exchanges for people to begin enrolling in eight months from now. And that requires coaxing many states that have balked at going along with one or both of those provisions.

The lack of action so far on insurance exchanges in many states has left the administration scrambling to organize about 30 federally run exchanges. That is far more than was envisioned by the authors of the health law and may stretch the CMS to the breaking point, said Bruce Vladeck, former administrator of the CMS' predecessor agency under President Bill Clinton.

“No one budgeted for the CMS to run exchanges in 30-some states,” he said.

The federal government may need to step in if states fail this year to implement major statutory changes to their local health insurance rules, said Sara Collins, a vice president at the Commonwealth Fund. The law requires changes in each state's rules for insurance sold outside of the exchanges, such as new limitations on the use of beneficiaries' ages to set the price of insurance policies.

“If it's not done, then the feds would need to step in and do it for them,” Collins said.

All of this will occur in the face of continued Republican opposition to the underlying healthcare overhaul. Despite some Republican governors reluctantly embracing aspects of the healthcare law in their states, congressional Republican leaders remained committed to unraveling a law they see as a massive expansion of federal power and an unsustainable long-term entitlement.

“Congress is looming over all of this and waiting for it to fail,” said Marilyn Moon, senior vice president and director of the Health Program at the American Institutes of Research.

Obama also is expected to face rising pressure in 2013 to undertake a significant federal debt-reduction effort that slows the growth of federal healthcare programs. The president could respond to Republican demands for moving Medicare to a premium support model or shifting Medicaid to state block grants with accelerated implementation of Medicare cost-saving pilots contained in the reform law, said some health policy experts.

“It's a matter of how do you move from voluntary pilots to an actual change in the payment approach that would succeed,” said Paul Ginsburg, president of the Center for Studying Health System Change.

Obama also could push reducing the tax exclusivity for employer-provided health insurance, Ginsburg said. Although such tax changes are highly controversial, they may provide the basis for the administration to find at least a small amount of bipartisan agreement this year.

“That's very consistent with the interest in both political parties in broadening the tax base and closing loopholes,” he said.