Threats to reform growing

With bipartisan pressure mounting to delay the healthcare reform law's individual mandate, the fate of President Barack Obama's landmark achievement may rest on how quickly his administration can get the online enrollment process working effectively. But most political observers don't expect any delay at this time in the requirement that nearly all Americans sign up for insurance coverage by March 31.

The success of the law's insurance reforms depends largely on getting a large number of Americans, including lots of healthy people, to sign up for coverage through the federal and state-run exchanges. The administration recently launched a “tech surge,” bringing in a website management czar and IT experts to fix the massive enrollment problems.

But up to now, enrollment—particularly on the federal HealthCare.gov exchange website serving 36 states—has been slow and consumers have faced problems getting needed information. That has prompted many Republicans and some Democrats to call for pushing back the enrollment deadline so people experiencing technological problems in signing up aren't hit with the law's tax penalty for not getting coverage.

In addition, there is growing political pressure to at least temporarily allow Americans with individual-market coverage to keep policies that are being canceled by insurers because they don't meet the cost-sharing and benefit requirements of the Patient Protection and Affordable Care Act. Sen. Mary Landrieu (D-La.) last week said she would propose a bill to ensure everyone could keep their existing coverage.

Political momentum for a mandate delay continued to build last week, especially among Democrats facing re-election next year. Nine House Democrats co-sponsored a bill that would give consumers 90 days to enroll after HHS' Office of the Inspector General certified that HealthCare.gov is completely operational, then delay the mandate penalty for another 30 days after that. On the Republican side, Sen. Marco Rubio of Florida introduced legislation to postpone the individual mandate until six months after the Government Accountability Office deems that HealthCare.gov is fully functional. The week before, 10 Senate Democrats wrote to Obama urging him to extend open enrollment for an indefinite period.

But Julius Hobson, a veteran healthcare lobbyist and senior policy adviser at the law firm Polsinelli, said he doesn't think the political momentum of the moment is strong enough to delay the mandate. He doubts that Senate Majority Leader Harry Reid (D-Nev.) would ever bring the House Democrats' delay bill to the floor. But while there might not be enough political pressure now, that could change.

“Everything has focused on the website and nothing else,” Hobson said. “They need to work out all the issues that are necessary, or otherwise momentum will pick up.”

On the other hand, Joseph Antos, a healthcare analyst at the American Enterprise Institute, a right-of-center think tank, said he thinks a delay in the penalty for not obtaining coverage is possible. “If they can't get their act together, and they don't make their November deadline, it's really hard to argue you will hold people accountable for coverage,” he said.

Joel Ario, a managing director for Manatt Health Solutions who formerly ran the CMS' health exchanges office, said he doesn't expect a delay in the individual mandate primarily because many state-run exchanges are generally operating well. Even so, he predicted there will continue to be calls for delaying the individual mandate until the federal website is fixed. “If it is fixed, nobody will remember it in six months,” Ario said. “If it doesn't get fixed, the administration will face some decisions—and there are no good options.”

Meanwhile, analysts worry about the ripple effects that a delay would have on the law's health insurance exchanges. Edwin Park, vice president for health policy at the left-of-center Center on Budget and Policy Priorities, pointed to a Congressional Budget Office analysis of the House-passed bill to delay the individual mandate that estimated a yearlong delay would increase the number of uninsured Americans by 11 million in 2014.

At last week's House Ways and Means Committee hearing on the botched rollout of the federal website, panel Chairman Dave Camp (R-Mich.) said it appears unlikely that the exchange plans will enroll enough young and healthy adults in the first year—about 2.3 million by the CMS' estimate—which will cause premiums to “go through the roof” in 2015.

But CMS Administrator Marilyn Tavenner countered by saying more than 200 insurers in the federal exchange alone have offered more than 3,000 plans at competitive prices. “So far what we've seen is the absolute opposite of what you're suggesting,” she said.

Both Tavenner and HHS Secretary Kathleen Sebelius—who testified last week before the House Energy and Commerce Committee—faced aggressive questioning from lawmakers about problems with the federal website; decisions that HHS and the CMS made before the Oct. 1 launch of open enrollment; privacy and security protections for consumers; the accountability of federal contractors working on the federal exchange; and Obama's earlier promise that those Americans who like their health insurance plans can keep them. They offered apologies for what Sebelius called the HealthCare.gov “debacle,” and promised that the federal website will operate smoothly and effectively for most consumers by late November.

Lawmakers also pressed both officials to provide details on the number of enrollees so far, which administration officials have said repeatedly they will release in mid-November.

Meanwhile, administration officials have said they expect early enrollment to be low. In a speech in Boston last week, Obama reminded Americans that the start of Massachusetts' ultimately successful healthcare reform seven years ago was similarly slow. He said the nation will overcome the early challenges.

Critics say that optimism is not supported so far. “In the end, what will matter is not speeches but whether Bill Smith will be able to have some mechanism that does not require the patience of Job to get signed up,” Antos said. “And there's no evidence of that.”

Follow Jessica Zigmond on Twitter: @MHjzigmond