Three Years On, States Still Struggle With Health Care Law Messaging After all the acrimony and debate, many Americans still don't know whether their states are going to expand Medicaid or set up health care exchanges. A lot of the confusion over the Affordable Care Act comes, in part, from a commanding "misinformation and disinformation" campaign.
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Three Years On, States Still Struggle With Health Care Law Messaging

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Three Years On, States Still Struggle With Health Care Law Messaging

Three Years On, States Still Struggle With Health Care Law Messaging

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  • <iframe src="" width="100%" height="290" frameborder="0" scrolling="no" title="NPR embedded audio player">
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It's WEEKENDS on ALL THINGS CONSIDERED from NPR News. I'm Laura Sullivan.

Coming up, a surprising look into the world's biggest smartphone seller. Bet you think we're talking about Apple. And when sports and politics collide, Dave Zirin on his new book.

But first, is it actually possible Americans know less about Obamacare now than they did three years ago? Apparently, that is the case according to a new poll.

It's hard to imagine after three years of acrimony and debate, we could still be so confused about a law. It couldn't come at a worse time, just as the most sweeping effects of the Affordable Care Act are about to kick in. That's our cover story today: Where exactly are we when it comes to this law, and why do we keep getting it so wrong?

AL WORTOSTELPINO: What do I know about it? I don't know that much about it.

SULLIVAN: That's Al Wortostelpino(ph) on the street of Charlotte, North Carolina, where we asked him and a lot of others what they know about the Affordable Care Act's mandatory health care exchange.

JOHN MORRIS: That's the issue that the governors are all fighting over, right?

DOROTHY LINDSEY: I don't know a lot about it, but I heard a lot of people talking about it.

VIC WARANNY: I know nothing.

JASON FOREMAN: The exchange might be a little bit daunting for me to try to navigate because no one can tell us exactly what it means.

SULLIVAN: That's John Morris, Dorothy Lindsey, Vic Waranny(ph) and Jason Foreman. And folks just outside Milwaukee didn't fare much better.

LORRAINE RANDALL: Actually, I'm not sure what the Affordable Health Care is going to do.

MARGARET GUNDERSON: I have a vague understanding about exchanges.

ROBERT HOLSIER: I'm unfamiliar with it, and most of my friends are skeptical because they don't know that much about it.

SULLIVAN: That's Lorraine Randall(ph), Margaret Gunderson(ph) and Robert Holsier(ph). And they're just like the rest of us. A new poll by the Kaiser Family Foundation finds 80 percent of people don't know whether their states is going to expand Medicaid under the law, a huge piece of the health care changes coming down the pike.

Half of people don't know whether their states are going to be setting up one of these so-called exchanges. Half of people think the law gives undocumented immigrants health care subsidies - it doesn't. Forty percent of people still think the government is going to set up death panels - it won't. And this was interesting. Just 37 percent of people say they like the law.

But when Kaiser asked people about specific things within the law, like providing tax credits to small businesses, insuring the sick, the overwhelming majority - 70 percent of people - say those are great ideas. I asked NPR's health policy correspondent Julie Rovner why we are so confused.

JULIE ROVNER, BYLINE: I think partly because there has been a very commanding misinformation and disinformation campaign, and it has worked better than the people who are trying to put the law into effect, who have been working to put the law into effect rather than to message about it.

SULLIVAN: So what is actually happening with Obamacare right now in year three?

ROVNER: There are really three big pieces of this law. And the first part of the law has mostly taken effect, and that is the insurance reforms. And that's what's known, really, as this patients' bill of rights that they tried to pass in the late 1990s. That's things like letting adult children to stay on their parents' plans until they turn 26, outlying annual and lifetime limits on insurance policies, and not letting health plans cancel coverage after the fact if you get sick.

SULLIVAN: And this is the good stuff. I mean, this is the stuff that most Americans, when you ask them in polls, say we love this. This is great.

ROVNER: Absolutely.

SULLIVAN: OK. So that's the first part. What's the second part?

ROVNER: The second part is what I call quality and cost, and this is mostly behind-the-scene stuff, mostly in Medicare because that's what the government has most control over. It's designing ways to change the way health care is delivered to improve the care patients get, to make care more efficient and, hopefully, to save money for both the patients and the government.

SULLIVAN: And then we have part three, which is the big dollop. I mean, this is the thing that's been the big controversial piece.

ROVNER: That's right. And this starts next January 1st, is getting as many as 30 million more people health insurance.

SULLIVAN: This is the mandatory health insurance. You must get health insurance or you have to pay a penalty.

ROVNER: That's right. And it actually really rolls out this October, which is when small businesses and people without insurance can start enrolling in these so-called health exchanges. That's where they'll be able to shop for health plans if they have moderate incomes. They'll be eligible for subsidies from the federal government to help pay for the plans.

If they have low incomes and if their state decides to accept the option, they can qualify for Medicaid. But remember, the Supreme Court made the Medicaid expansion optional last year, so we're still waiting to see how many states take up the federal government's offer to pay most of that cost. So far, it's just shy of half the states, but that could change.

SULLIVAN: OK. So about nine million people starting in about six months are going to go onto these exchanges, this website, and they're going to start picking a health insurance.

ROVNER: That's right.

SULLIVAN: Is this solving our national health care problem?

ROVNER: It's a step towards solving the national health care problem. It's expected to be a way for people to be able to compare health insurance. They'll get help paying for it. You can compare apples to apples. Insurers won't be able to discriminate against people with pre-existing conditions. This will be a place for people to go who can't get insurance now and a place where people will have to go since most people will be required to have insurance.

SULLIVAN: Are there still going to be millions of Americans who won't have health insurance after this is all said and done? Are there people who are going to fall through some sort of loophole here?

ROVNER: States that do not expand Medicaid, there will be a number of people who then are not eligible for Medicaid and are not eligible to get insurance at these exchanges. And there could be millions of people who will fall through the cracks who were originally anticipated to get coverage through this law.

SULLIVAN: So there are people who are not poor enough to get Medicaid - their state hasn't expanded Medicaid - but at the same time they're not going to be able to afford to buy this insurance on the exchange.

ROVNER: That's correct.

SULLIVAN: NPR's health policy correspondent Julie Rovner.

So here's where we are: If you're uninsured - whether you're a 22-year-old working in a coffee shop or a 58-year-old kicked off another insurance plan - you will have to buy insurance by next January or you're going to get a tax penalty. For the most part, there are some exceptions. The idea was that every state would create its own health care exchange, which is just a fancy way of saying each state would build a website and offer folks a sampler platter of low-cost insurance options.

But the law gave states a chance to opt out of creating one. And 26 states - mostly red states and mostly on ideological grounds - have done just that. It doesn't mean the exchanges aren't coming or that people in those states won't have to get insured. It just means the federal government will build the exchanges for them.

RON COOKSTON: Texas has the distinction of having the most uninsured people as a percentage of the total population of any place in the country.

SULLIVAN: Ron Cookston is executive director of Gateway to Care. It's a nonprofit health care advocacy group that works in the Houston area, in a state choosing to opt out of building its own health care exchange.

Almost 30 percent of adults in Texas lack health insurance according to Gallup. Ron Cookston and other advocates have to find a way to reach out to all of those people and let them know what's coming.

COOKSTON: The state of Texas - and I'm sure it's true in all the other 26 states - have great capabilities, and it would have been wonderful if since the passage of the Affordable Care Act, they had begun to help communicate and inform our public so that they would be ready. People just don't have any idea how they're going to be impacted.

SULLIVAN: Even people who work for Cookston's own health care advocacy group don't fully understand the requirements.

COOKSTON: I'm embarrassed to have to admit it, but I've got two staff that don't take the health insurance I offer. It wasn't until conversation in a staff meeting this week where it finally dawned on them that they're going to have to do something as well. These two individuals work to help people access health care every single day, but even they had not really understood that they, as an individual, are going to have to take responsibility.

SULLIVAN: Texas Governor Rick Perry has been outspoken in his opposition to Obamacare. He says it's bad policy. And he's rejected expanding Medicaid, which would have given health insurance to more than a million poor Texans.

COOKSTON: When leadership in any state talks about things in a negative way, it becomes awfully easy for the general public to sort of dismiss it.

SULLIVAN: The federal government is going to send organizations, like Cookston's, some money to help get the word out. But Cookston says what they're missing is a coordinating central body.

COOKSTON: The government of the state of Texas, they are not doing anything at this point in time. Are Texans paying attention and beginning to work together all over the state in Lubbock and in San Antonio and in Dallas and Houston to begin to develop ways to get the word out? We certainly are, neighborhood by neighborhood, because that's how this will have to be done - church by church, community by community. But unfortunately, we have not had the support of the government of the state of Texas.

SULLIVAN: So that's Texas at the moment - advocacy groups on shoestring budgets going church to church. Here's what's happening in California.

PETER LEE: Doing consumer surveys, marketing, focus groups. So come this summer, we're going to hit the ground in a big way with messages that we know will resonate for those that speak Spanish, speak English, speak Mandarin.

SULLIVAN: That's Peter Lee, and he's running California's health care effort. And the state has opted in. California is building its own exchange, giving it a catchy new name. They've called it Covered California. The state's hiring thousands of people to get it off the ground, and the federal government is giving the state $900 million to do it.

LEE: So we have what we call the ground troops. We've issued a community-based grants program. We'll be funding groups in communities across the state that are based in faith-based organizations, schools, unions, because we know that delivering this message needs to come from your neighbor.

SULLIVAN: About two and a half million Californians will be eligible for subsidies through Covered California, and Lee says it's a diverse group of people.

LEE: We need to have outreach that speaks to farmers, people in rural communities, people that live in downtown urban sectors and literally in dozens of languages.

SULLIVAN: About half the states are following California's lead, setting up their own exchanges or doing it in partnership with the federal government, using what is essentially seed money from Washington to get them off the ground.

LEE: These are states that have said, let's get that venture capital funding from the federal government to set up an exchange that works right for our state. We want to not just control our destiny but get the federal resources to make it work for our state.

SULLIVAN: But for consumers, it doesn't matter if you're in Texas or California or anywhere else in the country, the law is clear: The uninsured are expected to get coverage by January. Whether those folks will be informed and ready to do so by then is not so clear.

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