The Affordable Care Act at age 3

The Obama administration can justifiably look back with pride at year three of its signature healthcare reform law, the Patient Protection and Affordable Care Act.

First and most significantly, it survived. President Barack Obama was re-elected. And the divided U.S. Supreme Court ruled that the individual mandate to purchase insurance was constitutional, which allowed the private insurance expansion to continue moving ahead.

Second, administrators at HHS succeeded in putting in place most of the regulatory framework for carrying out the law despite efforts on Capitol Hill to short-change implementation.

Third, the Medicaid expansion, which was supposed to reach about half of the more than 30 million people targeted for new insurance coverage under the law, became optional. But that will be a minor and short-lived blip in implementation. The signs point to most states—except bitter-enders like Texas and Virginia—jumping on board largely because of the powerful allure of federal cash.

In her third-year anniversary message, HHS Secretary Kathleen Sebelius noted the obvious economic benefits to providers from expanding Medicaid to cover the working poor when their jobs don't provide health insurance. “Covering more people will save all of us money by reducing the cost of uncompensated care,” she wrote.

But now comes the hard part—building the exchanges where people will go to obtain coverage and then getting people to sign up for this new benefit, one that will cost most of them at least some money for a product they have never purchased before and have no experience using. There likely will be significant glitches.

Administration officials last week promised that the exchanges will be ready to serve this largely low- and lower-middle income population. There are still skeptics. But even if the federal government and the states succeed in building well-functioning online insurance exchanges and line up navigators to help people, it doesn't guarantee the customers will come.

It may have been politically astute to postpone implementation until after the November election. But submerging reform as a political issue put on the backburner educating the uninsured about what Obamacare could mean for them. There is still widespread ignorance about the law.

Moreover, the political compromises necessary to get the law passed dictated that the nation will wind up with a patchwork quilt of state exchanges where the uninsured can go to buy coverage. The federally run exchange will cover the 30-plus states that opted out of building their own, again, largely for political reasons.

That makes running national ad campaigns to promote using the new exchanges—such as the massive effort launched by the CMS in 2004 to promote the new Medicare drug benefit—much more difficult. Moreover, the ACA failed to include money for an outreach campaign. There's zero likelihood that Congress will appropriate money for that purpose now.

That's why the efforts of a new group, Enroll America, chaired by Ron Pollack, executive director of Families USA, a low-income advocacy group, are so important. It has promised to conduct the missing outreach campaign.

However, the group has raised only a small fraction of the money needed to execute a classic marketing strategy. Instead, it has hired former Obama campaign officials to conduct the kind of micro-targeting that proved so effective at turning out low- to moderate-income voters, the very people who benefit most from the new law. Their task will be made simpler by the fact that two-thirds of the uninsured are in just a dozen states.

Insurers planning to sell policies on the new exchanges and healthcare systems that benefit from any drop in uncompensated care have much to gain from Enroll America's efforts. It would be a wise investment if they helped this new group meet its fundraising goals.

Merrill Goozner, Editor