mykeystrokes.com

After the government shutdown ended, attention shifted to the blips and seizures bedevilling the federal marketplace’s Web site, healthcare.gov. Thirty-four states, all but seven of them Republican-controlled, chose not to set up their own exchanges, leaving hundreds of millions of dollars in outreach funding on the table, and forcing their residents onto the federally-operated Web site at the center of the current uproar. Twenty-one of those states are also expected to refuse nearly three hundred billion dollars in federal funding to expand Medicaid coverage over the next decade, which would have extended care to more than six million people; a majority of those excluded will likely be African-Americans and single mothers. To compound the effects of their recalcitrance, conservative governors, state legislators, and members of Congress have also passed navigator-suppression measures in thirteen states—Arkansas, Florida, Georgia, Iowa, Illinois, Indiana, Maine, Missouri, Montana, Ohio, Tennessee, Texas, and Wisconsin—home to seventeen million people without insurance who are eligible for coverage under the A.C.A.

Two weeks after Ray received her grant, she was notified by the House Energy and Commerce Committee that she would have to participate in a phone interview with the committee’s staff in September; she was also asked to give written answers to half a dozen questions from the committee and provide “all documentation and communication related to your Navigator grant.” Similar notifications were sent to navigator offices in eleven of the most underinsured states in which residents will need to use the federal health-care exhange—including Texas, Florida, and Georgia, home to about a quarter of the nation’s uninsured. Representative Henry Waxman, a Democrat from California, protested, in an open letter to the committee’s chairman, Michigan Republican Fred Upton, that the requests appeared “to have been sent solely to divert the resources of small, local community groups, just as they are needed to help with the new health care law.”

On September 18th, Darrell Issa, the Republican chairman of the House Committee on Oversight and Government Reform, released a report that singled out Florida as the site of “numerous reports of scam artists posing as navigators and Assisters to take advantage of people’s confusion about ObamaCare.” On October 2nd, Fox News aired footage of volunteers for Get Covered America, a non-profit advocacy campaign, going door-to-door in a Miami suburb to distribute flyers about the new insurance marketplace—but wrongly identified them as federally-funded navigators, giving the impression that these “navigators” were hawking plans like pushy insurance salesmen. Upton linked to the report on his Web site. Ray, who still spends much of her time getting new navigators licensed while the federal government fixes the Web site’s glitches, was reticent about discussing the maelstrom of controversy. “It’s been busy,” she said.

As these tactics jam up early efforts in many states, they also amplify the contrast with successful rollouts in states that have wholeheartedly embraced the new law, like Colorado, Connecticut, New York, Kentucky, and Washington.

Elisabeth Benjamin, who leads New York’s largest team of navigators at the Community Service Society, spent much her early career improving health-care capacity in developing countries like India, Tunisia, and postwar Iraq—where, she said, people often told her, “I don’t understand why you’re in our country. You have a lot of problems with health care and poor people in your country.” Back home, she started a health-law unit at the Legal Aid Society to assist low-income New Yorkers with unforgiving medical bills. In 2008, she unveiled an insurance ombudsman program at C.S.S. to help people at every income level understand their options for medical coverage. “If you need a loaf of bread, it’s a buck,” she said, explaining health care’s central distinction from other forms of assistance. “If you need a transplant, it’s five hundred thousand dollars.”

Around the same time Benjamin was starting her program, Eliot Spitzer, then the governor of New York, proposed statewide health-care reform similar to the law Massachusetts had passed four years earlier. Vermont’s legislature had expanded coverage, and Arnold Schwarzenegger had made national news by calling for a similar program in California. Benjamin joined an affordable-health-care advocacy campaign, Healthcare for All New York, and testified before the New York State Legislature. “We just assumed there would be a state-by-state movement to extend coverage,” Benjamin said. But two years later, the Obama Administration, with the help of a Democrat-controlled House and Senate, passed the Affordable Care Act. New York’s governor, Andrew Cuomo, along with the state legislature in Albany, accepted the expansion of Medicaid, and the state established its own online exchange. After the Supreme Court upheld the constitutionality of Obamacare, in June, 2012, Cuomo released a statement that said, “We look forward to continuing to work together with the Obama administration to ensure accessible, quality care for all New Yorkers.”

That spirit of coöperation has been integral to New York’s early success. Elisabeth Benjamin, in New York, and Jodi Ray, in Florida, offer exactly the same services to people who were previously unable to obtain medical coverage: they help determine voucher amounts, parse available options, and submit applications online, over the phone, or through the mail. But because New York set up its own exchange, the state received twenty-seven million dollars to fund its navigators, while Florida has just eight million dollars for outreach. Benjamin, who is herself a trained navigator, conceded that there were glitches on New York’s Web site the first week, but said that most of them have been resolved. In the second week, she helped enroll a woman who had worked as a home-health-care aid for twenty years, earning around twenty-four thousand dollars annually. Home health care “has to be the hardest job in America—so physically taxing and emotionally draining,” Benjamin said. “And we don’t give them health coverage. Are you kidding me? They’re part of the health-care system.” Benjamin helped find a plan for the woman that costs seventy-two dollars a month. “I was crying,” Benjamin said. “That’s what it’s all about.”

For the A.C.A. to succeed in its goal of providing coverage for all citizens at an overall reduction in cost, a critical mass of people—old and young, sick and healthy—will need to participate in the insurance exchanges. As of October 23rd, New York had enrolled thirty-seven thousand people, more than twice the goal set by H.H.S. for the entire month of October. Florida won’t know how many people have enrolled until H.H.S. releases its figures sometime in November. The Congressional Budget Office has estimated that a total of seven million people nationwide could enroll in the first year. But Dr. Kavita Patel, a health-care-reform expert at the Brookings Institution, and a former policy advisor in the Obama Administration, told me, “If by the end of 2014 there are three million people enrolled, that would be a success.” The politicians who are currently bemoaning the looming failure of Obamacare might consider doing more to help navigators like Jodi Ray make it work.

By: Rob Fischer, The New Yorker, November 1, 2013