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Implementation Of Obamacare Remains A Work In Progress

LINDA WERTHEIMER, HOST:

Last week the Supreme Court affirmed the Affordable Care Act. The Court ruled that the federal government can provide subsidies to millions of Americans in states that have not set up health insurance exchanges. But that decision does not mean troubles are over for the law. Julie Rovner of Kaiser Health News spoke to our colleague Renee Montagne about some of the flaws that still need to be fixed.

RENEE MONTAGNE, HOST:

Nice to have you back in the studio, Julie.

JULIE ROVNER, BYLINE: Nice to be here, Renee.

MONTAGNE: The law survived this challenge, but what are the long-term prospects for healthcare in the states that have refused to set up their own exchanges, which is what this challenge originally was all about?

ROVNER: That's right. It's exactly what this challenge was all about. More than two-thirds of the states have not set up their own exchanges, and there was a lot of concern that had the Supreme Court ruled the other way, a lot of people would end up without their subsidies and likely without their health insurance. That didn't happen, so as we go forward, it looks like the states that didn't set up their own exchanges are going to be just fine.

MONTAGNE: What about the states that did set up their own exchanges? They were good soldiers. What about them?

ROVNER: Oddly enough, it's the states that did set up their own exchanges, in the way that the law anticipated, that are having problems. The way the exchanges are supposed to be self-financed is that each exchange gets a portion of the premium that's paid. The problem is, with some of the very small states, there's simply not enough people to support all the things that the exchanges have to do - including signing up people and outreach and education. So we've already seen Hawaii, for instance, shutter its exchange. It's going to go back and let the federal government do it. Oregon had a different problem; their IT system simply didn't work. So now they're using healthcare.gov, the federal IT system, but they're still doing some of the other activities on the state side. I think we may end up seeing more of that, where there's a sharing between the states and the federal government.

MONTAGNE: So far, how has enrollment been?

ROVNER: Enrollment has been OK. The exchanges have signed up about as many people as the Congressional Budget Office estimated, although they revised some of those estimates downward. It hasn't been enormous. There are still a lot of people who don't know either that there's a requirement for them to have health insurance, or that health insurance is available with subsidies, which it is.

Another issue has been the 20 or so states that have not expanded the Medicaid program. That was originally a requirement. The Supreme Court, in 2012, said, no, that has to be optional. And a number of states - even though the federal government is paying most of the cost of that - a number of states have decided not to do it. So you have people who are caught in what's called the gap. They make too much to qualify for Medicaid in their state, but they make not enough to qualify to buy on the exchanges. So you've got several million people, still, who will remain uninsured until something is done about that.

MONTAGNE: And of course the question of affordability is there since the beginning of the ACA - I mean, people complaining that they are paying more for their insurance under the Affordable Care Act.

ROVNER: Well, that's true, and it's not true. Premiums actually haven't gone up as much as a lot of people expected. What has happened that I think was unexpected is that the law requires many more benefits than many insurance plans had had before, things like maternity care and substance abuse care. What insurance companies have done is they have kept premiums relatively low, but they've increased deductibles - the amount you pay before you can get care. So many people now have insurance, but they have insurance with these multi-thousand-dollar deductibles. So they still can't afford to get care because they can't pay that money up front before they actually start to get benefits.

MONTAGNE: Julie Rovner is with Kaiser Health News. Thanks for joining us.

ROVNER: Thank you. Transcript provided by NPR, Copyright NPR.