By Sam Baker and Elise Viebeck - 07/04/13 02:20 PM EDT
This week’s stunning delay in the Affordable Care Act’s (ACA) employer mandate was hardly the first time that ObamaCare's implementation effort has stumbled, as the president's signature domestic policy initiative has suffered several self-inflicted wounds on the path toward full implementation.
While many of the administration’s challenges stem from entrenched Republican opposition to anything that would help the law function better, plenty of the bumps in the road so far have also arisen from the law itself.
As officials work to implement the law's biggest provisions, which also happen to be the policies that provide the clearest and most direct benefits to consumers, here is a recap of some of ObamaCare's biggest stumbles so far.
1. The CLASS Act
The healthcare law included a new insurance program for long-term care, known as the CLASS Act. The problem? It couldn’t be implemented as written. In October, 2011, Health and Human Services (HHS) Secretary Kathleen Sebelius announced she would indefinitely suspend work on the program, stating that it could not be financially viable.
With the death of CLASS, the law lost about 40 percent of its total deficit reduction. And Republicans criticized the program as an accounting gimmick, noting that budget analysts predicted before the law was passed that CLASS wouldn’t work.
It was formally repealed last year.
2. The federal insurance exchange
The ACA provides a literally unlimited budget to help states set up their own insurance exchanges — and no budget whatsoever for the federally run backup. So while HHS has shelled out billions of dollars to help 17 states build their own exchanges, it has had to scrape together money from other programs so that it can build the remaining 33 marketplaces.
Most observers say the lack of funding was simply an oversight. But the implications are real. HHS has come under fire from congressional Democrats for some of the cuts to programs to help pay for the federal marketplace, and it has said it needs another $1.5 billion for the exchanges — money Congress is highly unlikely to provide.
3. The employer mandate
The most recent stumble came on Tuesday, when the White House announced that it would delay enforcement of ObamaCare's employer mandate by one year. The mandate isn’t especially important to the law’s coverage expansion, but the delay fueled questions about whether the overall implementation effort is on track.
4. The small-business exchange
Before delaying the employer mandate, the administration pushed back another provision for business owners. HHS delayed by one year a part of the new insurance exchanges for small business. Although the exchanges will be up and running next year as planned, employers will have to wait another year before they can let their workers choose from a range of plans, rather than selecting just one for the entire company.
Once again, a political headache for the administration stemmed from an effort to give businesses more flexibility.
HHS approved more than 1,200 waivers from a provision of the healthcare law that gradually eliminated annual caps on benefits. The waivers themselves weren't scandalous — they were specifically authorized by the statute, and they dealt with a relatively minor requirement. But they turned into a messaging problem as Republicans used each new batch of waivers to argue that the law was unworkable.
HHS updated its waiver figure every month until last year, prompting a political firestorm each time. Finally, it quit the monthly updates and granted a long extension that put the issue to rest.
This widely criticized “1099” reporting requirement, named for the tax form it would have used, was the first ObamaCare provision to be repealed. The mandate compelled businesses to report nearly all transactions worth more than $600 to the IRS.
Business groups characterized the provision as red tape, and lawmakers worked for nearly eight months to kill it. Repeal passed with broad bipartisan support in both chambers, and as Obama signed it, he said the provision was an example of a problem in the healthcare law that Republicans and Democrats could work together to fix.
7. Child-only plans
A glitch in the healthcare law prompted insurance companies to quit selling policies in several states that only covered children. Starting in 2010, insurance companies had to cover children’s pre-existing conditions if they sold child-only plans — but they weren’t required to sell child-only policies in the first place. So, rather than take on the additional cost, some insurers quit writing new policies just for children.
Again, state insurance regulators said the gap in children’s coverage looked like an oversight — the kind Congress might have fixed in conference, if there had been a conference on the healthcare bill.
The $5 billion Pre-Existing Conditions Insurance Plan (PCIP) offered health coverage to sick patients waiting for full implementation of ObamaCare. But the program initially failed to enroll as many people as expected, and was plagued by high costs. In February, HHS stopped accepting new applicants into the program to ensure it would have enough money to cover the people already enrolled.
"Running out of money before the end of the year is something we're trying to avoid," said Gary Cohen, director of the federal Center for Consumer Information and Insurance Oversight, in congressional testimony.
9. The Basic Health Plan
Democrats and state-level advocates were incredibly frustrated with HHS’s decision to delay a program known as the Basic Health Plan. The provision would let states bargain directly with insurance companies to create a scaled-down plan for people who aren’t eligible for Medicaid but might not be able to afford the more expensive private plans sold through the exchanges.
Its implementation was pushed to 2015 — another casualty of the intense focus on exchanges and the Medicaid expansion. Sen. Maria Cantwell (D-Wash.) had threatened to block a top healthcare nominee until HHS answered her questions about the delay and pledged to have the program up and running in 2015.
10. ObamaCare for congressional staff
During the legislative debate, Democrats accepted a GOP amendment saying members of Congress and their staffs had to use ObamaCare. But no one is quite sure how to implement the provision without putting staffers at a huge disadvantage.
The federal government, like all large employers that offer health benefits, pays for a portion of its employees’ healthcare costs. The question now is whether staff can put that contribution toward the purchase of an ObamaCare-compliant policy.
Forcing staffers to lose their employer contribution would treat them as if they didn’t work for an employer that offers health benefits, even though they do, and it would make jobs on the Hill much less attractive to young and mid-level staffers. But Republicans say they won’t help staff keep their employer contributions, even to buy a policy through an ObamaCare exchange.