Brandi Griffith, a South Carolina small-business owner who considers herself a conservative, shares a dislike of President Barack Obama’s $1.3 trillion Affordable Care Act with Nikki Haley, her Tea Party-backed Republican governor.
Even so, Griffith, a 35-year-old single mother, can’t afford $700-a-month premiums and wants to buy subsidized insurance in the marketplace the measure creates. She’s counting on Haley and fellow Republicans not to make that harder. South Carolina, one of 26 U.S. states that decided to let the federal government run the so-called health exchange, returned all but $18,500 of a $441,000 consumer-assistance grant, and Republican lawmakers want to “nullify” the law.
“If the state’s not supporting it, I think the resources will be limited,” Griffith, who runs an event-management company in North Charleston, said in a telephone interview. “It will make it much more difficult for consumers like me.”
Advocates for the 900,000 uninsured people in South Carolina say that thousands may not be able to enroll because the state isn’t helping implement the exchange. While the Obama administration says all exchanges will open on time Oct. 1 to cover as many as 27 million people, success in reaching them may depend on states’ willingness to help. Those states are exhibiting a continuum of cooperation.
“We have seen no real attempts for the state to work with the federal government at all,” Sue Berkowitz, director of the South Carolina Appleseed Legal Justice Center, a Columbia nonprofit helping the poor, said in an interview. “Not working with the feds is, in itself, a hostile move to keep people from being able to benefit.”
South Carolina is upgrading its Medicaid system, the state-federal health insurance program for the poor, to interface with the new online marketplace. But officials are relying on the U.S. government to promote and run it, said Tony Keck, Haley’s director of the Health and Human Services Department.
“This is a federal law, it’s a federal exchange, there are federal changes to federal law,” Keck said in an interview. “The feds should be implementing it.”
The U.S. Health and Human Services Department said in an e-mail statement that the marketplaces will open on time in South Carolina and all other states, and that it is working with states to provide needed flexibility, resources and time to set up the exchanges.
Most Americans are required to carry insurance beginning Jan. 1 under the law, which allowed states to opt out of setting up exchanges with subsidized coverage for the poor.
Seventeen states and Washington, D.C., are creating their own marketplaces, seven formed partnerships with the federal government and 26 chose to let the U.S. government shoulder the burden, according to the Center on Health Insurance Reforms at Georgetown University.
Cooperation among holdouts varies. Nebraska is creating a commission to improve its marketplace, even though the state isn’t running it. Missouri, however, prohibited state workers from helping U.S. authorities create or run its exchange.
“The states that don’t cooperate here are making it harder for their consumers to reach what they’re entitled to under the law,” said Joel Ario, a former director of the federal Office of Health Insurance Exchanges who’s managing director of Manatt Health Solutions, a Washington consulting firm that advises insurers.
There could be delays in determining whether residents can get subsidies or Medicaid benefits if a state doesn’t create an effective interface with a federal computer hub, said Daniel Schuyler, a director at Leavitt Partners in Salt Lake City, Utah, who advises states on exchanges.
Schuyler said in a telephone interview that “it’s fair to assume” that recalcitrance will hamper the ability of federal authorities to run exchanges.
In Missouri, a law says no state worker or official “shall provide assistance or resources of any kind” to foster a federal exchange unless that help is required by another state or U.S. law.
While the state Medicaid agency is working with the exchange to enable it to check eligibility, the Insurance Department won’t act for fear of being sued, said Ryan Barker at the Missouri Foundation for Health, a philanthropy serving the uninsured and underserved.
While the federal government is issuing “navigator” grants to organizations to help consumers enroll, that won’t be sufficient, Barker said. The foundation is spending $1.2 million this year of its own for advertising and $2.8 million to train counselors, he said.
“We’re going to do our best, but if we don’t have the resources, people are going to fall through the cracks,” Barker said.
By contrast, New York, which is creating its own exchange, plans to spend $27 million next year training an army of brokers and consumer groups to help residents enroll. It’s working with an advertising firm to reach the state’s 2.6 million uninsured residents.
In South Carolina, Haley cited a lack of flexibility and unclear federal guidelines in a Nov. 15 letter declining to create an exchange. She also has opposed the law’s provision expanding Medicaid, calling Obama’s approach a “public-policy disaster.”
Seventeen percent of South Carolinians live in poverty.
Republicans won’t do anything to make the exchanges work, said Democratic State Representative J. Todd Rutherford, the House minority leader. He said the House passed a measure May 1 meant to render the health-care law “null and void” and to bar state workers from action “that aids any agency in the enforcement.”
“They are so against President Obama that they are willing to put the lives of the citizens of South Carolina in jeopardy,” Rutherford said in an interview after a House session.
The state is focusing on serving residents by making its existing Medicaid system better, and cooperation with the exchange has been slowed by federal delays in issuing rules and procedures, said John Supra, chief information officer at the Health and Human Services Department.
When residents call the state for assistance with insurance, they’ll be referred to federal authorities, said Raymond Farmer, director of the South Carolina Insurance Department.
“It’s going to be heartbreaking not to be able to help somebody, but it’s not our exchange,” Farmer said in an interview.
A well-functioning exchange would get uninsured residents earlier care to avoid more expensive treatment, said Woodrow Bell, 47, a doctor at Eau Claire Cooperative Health Centers in Columbia.
Twenty percent of South Carolina’s 4.7 million residents are uninsured, including almost 164,000 children, according to the Kaiser Family Foundation. The state has the ninth-lowest life expectancy and is tied for the fifth-highest infant death rate among states, Kaiser said.
As many as 60 percent of the patients Bell sees each year lack coverage, and 40 percent don’t have access to the Internet to help them enroll in the exchanges without help. Navigating the exchange alone “is going to be a daunting challenge,” Bell said in an interview in his office, as children, adults and seniors waited for care.
Jacqueline Harris, 62, a Columbia resident and one of Bell’s patients, lost her health coverage when her company downsized last year. Harris, who was treated for kidney cancer six years ago, said she’s “disgusted” the state isn’t doing more.
“How can you deny your citizens?” she asked.