Democrats' healthcare reform law, already challenged by Republicans who want to repeal it and state officials who want to ignore it, faces yet another challenge from a disengaged public.
States across the country are reporting lower than expected participation in the high-risk pools for people with pre-existing conditions, raising concerns that a lack of public engagement could affect the program's success — and that of health reform more generally.
"What the press seems to cover is all the negative arguments going on about healthcare reform, and I think people are put off by that and don't take advantage of this opportunity that's available because they don't know what's at stake," said Jean Hall, an associate research professor at the University of Kansas.
Hall, who studies high-risk pools with support from the Commonwealth Fund, said most states are reporting lower-than-expected participation in the program. The Department of Health and Human Services has yet to release state-by-state statistics on the high-risk pools, but press accounts confirm a slow start.
Iowa, for example, had received only 32 applications by the middle of this week, even though state officials told the Des Moines Register that they were expecting many more because the pool's premiums are "much cheaper" than those in the state's long-standing pool.
Iowa state Rep. Linda Upmeyer, a Republican, was quoted by the newspaper as saying skepticism about the new law may be partly to blame for the low enrollment, even if she personally would advise people to look into the new high-risk option.
"This might be a really good example of people not signing up because they don't trust government to make healthcare decisions for them," Upmeyer told the Register.
Kansas Insurance Commissioner Sandy Praeger, a Republican who chairs the Health Insurance and Managed Care Committee at the National Association of Insurance Commissioners, offered a different take. She said the high cost of premiums and out-of-pocket costs was to blame for the slow movement in Kansas, where only 17 people had enrolled by Friday in a program that started taking applications in mid-August.
"Things are kind of slow to get up and running," Praeger told The Hill. "They're up and running, but enrollees aren't breaking down the door."
Praeger said the Kansas pool has a $2,500 deductible, which is still unaffordable for many potential beneficiaries.
Hall said more people would participate in the new pools if they knew that they offer much lower rates than the older state programs, but that message is getting tuned out. One high-risk pool official told Hall it was hard to buy advertising space to promote the program because it's all taken up by campaigns.
"If they were put off by the cost, that's one thing, but I don't think they've even checked into it yet," Hall said. "People are not knocking on the door."
The healthcare reform law mandates that the high-risk pools offer premiums that mirror the market rates in each state, Hall said. States are free to decide whether to charge older people more (a ratio of up to 4:1 is allowed under the law) and some states, such as Pennsylvania, are charging people of all ages equally.
Hall said she expects the public will see the benefits of the high-risk pools more clearly after the election, especially since Republican foes of the healthcare reform law have embraced the concept in the past.
But the broader issue of public participation in healthcare reform remains, Praeger said. If costs aren't kept under control, she expects many young healthy people won't buy coverage in 2014 when stricter rules for insurers begin, likely endangering the financial viability of insurance companies.
"I think the individual mandate's going to be a problem," Praeger said. "I think young healthy people aren't going to participate, but again, it's going to be back to price."