Implementing Obamacare in a Red State — Dispatch from North Carolina — NEJM:
North Carolina's decision not to participate in Obamacare has had an enormous impact. An estimated 319,000 uninsured North Carolinians with annual incomes below the federal poverty level ($11,490 for an individual) are ineligible for Medicaid because the state rejected program expansion. These low-income people are also ineligible for subsidized coverage in the North Carolina exchange, which leaves them without any new affordable insurance options, even as people with higher incomes are eligible for subsidies through the exchange. In other words, many North Carolinians are actually too poor to qualify for financial assistance to obtain insurance — further testament to the bizarre logic of American health care. Consequently, it is projected that by 2016, North Carolina will have reduced its uninsured population of 1.6 million by only about 400,000. Hospitals, doctors, and safety-net clinics will see a higher volume of uninsured patients than they would have seen if the state had expanded Medicaid — an especially problematic outcome for hospitals that had counted on more insured patients to balance out financial pressures from reductions in federal Medicare payments.A higher number of uninsured residents is not the only consequence of North Carolina's Obamacare boycott. North Carolinians are dependent on the federally run insurance exchange, with all the problems that has entailed to date. States rejecting Medicaid expansion still have many residents who are eligible under the ACA for subsidized coverage in the exchanges. But the uninsured must first learn about new coverage options. Yet the North Carolina state government has played virtually no role during the run-up to and early operation of the insurance marketplace. There is no state-organized outreach and enrollment effort, no state campaign to raise awareness about new coverage options, and no state-led drive to cover hard-to-reach populations such as immigrants. Into that void has stepped a loose coalition of community groups, health system stakeholders, and social-service providers. In addition, Enroll America, a nonprofit group working to promote the ACA in states whose governments are not running their own exchanges, has set up shop in North Carolina. It aims to use techniques adapted from the Obama presidential campaign to identify, find, and canvass uninsured persons and connect them to enrollment resources. Enroll America plans to purchase advertising promoting the ACA in North Carolina, something the Obama administration is also doing.In other words, because North Carolina is not organizing health care reform implementation, that task has, by default, fallen to groups outside state government. For all their efforts, such groups lack the resources, authority, coordinating ability, and presence that would have accompanied a state-organized campaign to implement Obamacare. State inaction further devolves responsibility to county public agencies, which may vary in their receptiveness to and capacity for ACA promotion. Moreover, the pro-Obamacare campaign must compete with a robust anti-Obamacare operation led by Republicans and conservative political organizations.
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