Looking Past Website, More Challenges Await Obamacare

An increasing number of people are signing up for health insurance through the government's new exchange, suggesting the Obama administration has made progress in fixing its broken website. But the exchange is just one part of the health care law, which remains politically divisive almost four years after its passage.

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When the federal website selling new policies under Obamacare started crashing, President Obama insisted on a broader perspective. The Affordable Care Act, he said again and again in a news conference, was more than a website. Now, more people are signing up for health insurance on the federal government's exchange, and that turns the focus on the other parts of the huge law, which has been divisive since its beginnings. NPR's Scott Horsley reports.

SCOTT HORSLEY, BYLINE: President Obama was philosophical last week as he talked with young people at the White House about the costs and benefits of his signature health care law.

PRESIDENT BARACK OBAMA: About a year ago, I got a letter from a woman in her 20s. She had just graduated from law school and she wrote: Thank you for making health care reform a priority. If you hadn't, you probably would have fewer gray hairs right now.

(LAUGHTER)

HORSLEY: But these are gray hairs the president volunteered for. Unlike the wars he inherited or the stimulus, the auto bailout and the financial overhaul that were forced on him by the economic crisis, the new health care law was a deliberate choice.

OBAMA: We did not come here just to clean up crises. We came here to build a future.

(APPLAUSE)

HORSLEY: As ambitious as he was in tackling health care, though, Obama also showed characteristic caution. He rejected both a single-payer, Medicare-for-all model that some on the left were clamoring for and the proposal championed by Republicans, like John McCain, which could have caused big changes to the employer-based insurance that millions of Americans rely on. Instead, Obama tried to chart a middle course that would extend coverage to many of the uninsured while minimizing the disruption for everyone else.

OBAMA: If you are among the hundreds of millions of Americans who already have health insurance through your job or Medicare or Medicaid or the VA, nothing in this plan will require you or your employer to change the coverage or the doctor that you have.

(APPLAUSE)

HORSLEY: Despite that reassuring mantra, which would come back to haunt the president, the law was polarizing from the start, and it triggered a public backlash.

CROWD: (Chanting) Kill the bill, kill the bill, kill the bill...

HORSLEY: When congressional Democrats finally passed the health care law, they did so with zero Republican support. That seemed like the end of a long struggle, but as Obama ruefully admitted last month, a lot of us didn't realize that passing the law was the easy part. Some of his allies understood that early on. Two months after the law was signed, Harvard economist David Cutler penned a memo to Larry Summers, one of the president's top advisers. He warned that the people and processes charged with implementing the law were not up to the task, and he recommended the administration bring in some outside experts to help set up the insurance exchange and carry out other tasks.

DAVID CUTLER: People have different kinds of skills. What they had early on in the administration, quite correctly, was people who had experience in working with Congress and working with interest groups to try and get something passed. When you then need to implement it, that's often a very different set of skills.

HORSLEY: Cutler doesn't consider this any deep insight; just management 101. What's more, he says, there were people both inside and outside the administration who shared his concerns. For whatever reason, though, Cutler's advice about hiring new people who could manage the complex operation was not heeded. Bill Galston, a former Clinton adviser who's now at the Brookings Institution, says that's a decision the president probably wishes he could do over.

BILL GALSTON: I conjecture that the president's decision not to go outside the White House reflected the fact that the circle of people whom he knew well and in whom he had confidence not just per competence but also for unswerving loyalty to him and to one another, was pretty small.

HORSLEY: If the White House developed a bunker mentality around the health care law, it wasn't entirely without reason. Throughout the process, approval of the new law never topped 50 percent, and it was partly backlash against it that cost Democrats their House majority in 2010. Over the next two years, Obama would earn more gray hairs if the law was subjected to constant legal and political challenges. While the Supreme Court narrowly upheld the law last year, it continued to be a target for Republicans, including the president's 2012 challenger, Mitt Romney.

MITT ROMNEY: If we want to get rid of Obamacare, we're going to have to replace President Obama. My mission is to make sure we do exactly that.

HORSLEY: The health care law has generally polled worse when it's labeled Obamacare, a term initially used as a GOP epithet. Obama himself eventually embraced the term during his re-election campaign when he tried to turn it into a rallying cry.

OBAMA: I have no problem with folks saying Obama cares. I do care.

HORSLEY: Ultimately, the president and his health care law survived the fight in Congress, the courts and at the ballot box, only to be tripped up by the administration's own missteps, and its failure, at least initially, to build a working website.

OBAMA: That's on me. I mean, we fumbled the rollout on this health care law.

HORSLEY: That unforced error by the administration rattled confidence not only on the health care law but in the larger mission so important to Democrats to show that government can play a positive role in people's lives. Obama acknowledged there's now a credibility gap he's going to have to fill.

OBAMA: There's going to be a lot of evaluation of how we got to this point. And I assure you that I've been asking a lot of questions about that.

HORSLEY: Harvard's Cutler says it's vital that the White House learn from this experience because even after the insurance website is working properly, the punch list of tasks needed to implement the health care law is far from finished. If anything, the insurance exchange was supposed to be the feel-good part of the law, extending quality coverage to millions of people with bad insurance or none at all. The other big goal is redesigning the delivery of health care so it's cheaper and better. Cutler says that would be enormously beneficial in the long run but it will mean reconsidering some procedures, narrowing some choices, and pushing both doctors and patients to make changes.

CUTLER: How they're perceived and how they actually happen really depends on how you carry it out. And that was always the worry of a lot of people, not that it's impossible to get it right, but just that you really have to work at it to get it right.

HORSLEY: Cutler says the initial phase of the Obamacare rollout is a textbook example of how not to manage a major project. The question now is whether the administration can turn it around.

CUTLER: Organizations make mistakes. The great sin in life is not learning from them.

HORSLEY: Cutler notes there are early signs the health care law is helping to slow the growth in health care costs, which could save the government and businesses hundreds of billions of dollars over time. Speaking to that gathering of youth leaders at the White House last week, Obama promised to keep improving the law. He warned that given the scale of the project, new problems are likely to surface in the months to come, but he said young people should not be put off.

OBAMA: Don't get discouraged. Be persistent. You may get a few gray hairs as a consequence, but I think at the end of the day you'll think it's worth it.

HORSLEY: One thing certain: the president's bold attempt to overhaul one-sixth of the U.S. economy will be a defining feature of Obama's legacy, for better or for worse. Scott Horsley, NPR News, Washington.

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Your Questions About The American Health Care Act

NPR's interactive guide to the Affordable Care Act. i i

NPR's interactive guide to the Affordable Care Act. NPR hide caption

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NPR's interactive guide to the Affordable Care Act.

NPR's interactive guide to the Affordable Care Act.

NPR

In recent months, NPR staff has published a series of questions-and-answer stories related to the Affordable Care Act, also known as Obamacare. Now we've compiled them into an interactive so you can explore answers that are most relevant to you.

There are nearly 80 questions, ranging from who's eligible to how much insurance might cost, among two dozen topics. Filter the list by selecting categories or asking questions.

Did we miss an important question? Let us know.