WASHINGTON -- When she logged onto Kentucky’s health insurance exchange website, Kimberly Cates did not have the problems that have plagued so many Americans trying to sign up for insurance under Obamacare. She browsed plans and compared them, and checked whether she was eligible for subsidies. Yet when it came time to actually enroll, she hesitated.

Cates has seen firsthand the consequences of not having coverage. For more than a decade, she has worked as a certified medical assistant in a family clinic in Paint Lick, Ky., that treats the uninsured and indigent. The irony is lost on no one that the clinic cannot afford to offer Cates health care benefits.

For years, insurance companies have eyed Cates' 5-foot, 245-pound stature and used it to either deny coverage or to offer her plans costing well beyond her means. As a result, the 40-year-old mother of three has been putting critical doctor visits and tests on her Visa. In February, she borrowed from an aunt to pay for her hysterectomy. A few years' health care bills added up to at least $15,000 -- more than half her yearly salary at the clinic.

Four days before Kentucky's health exchange, known as Kynect, launched on Oct. 1, Cates and her husband, Rodney, who collects disability due to a factory work injury, filed for bankruptcy. Now Cates was browsing the exchange website from the living room of a small apartment they found after losing their home. Cates and her husband had lived in an old farmhouse that had been in the family for generations, surrounded with flower gardens she tended. She needed Kynect to work and believed that it would.

After plugging in her information, the website produced two companies that offered plans. She'd heard of one. The other -- the nonprofit Kentucky Health Cooperative -- was foreign to her. The costs of the plans varied from $17 per month to $190 per month. They had high deductibles, and Cates wasn’t confident that any offered prescription drug coverage (they did). It was all very unfamiliar. Once she got to the point where she had to pick a plan, she started to cry.

“I’ve not had insurance for so long,” Cates says. “I didn’t get my hopes up." After logging out of Kynect, she says she decided that Obamacare was "just too good to be true.” It was not a statement of relief, but an expression of profound skepticism.

barack obama
Cates' farmhouse that she lost in part due to medical bills.

Kentucky has some 640,000 uninsured residents. Many have put aside whatever reservations they may have harbored toward President Barack Obama or Steve Beshear, the state’s Democratic governor, and have enrolled in the state's health exchange or joined the state's Medicaid expansion. More than 1,000 residents have signed up each day since Kynect opened.

The Bluegrass State’s successful Obamacare rollout has become a favorite retort to the embarrassment of a hobbled federal website. “Look at Kentucky. Gov. Steve Beshear, who's a Democrat -- he is like a man possessed with helping more people get coverage,” Obama said in a recent speech. “He thinks it's the right thing to do. Keep in mind I did not win in Kentucky. But there are a lot of uninsured people in Kentucky, and they're signing up.”

Beshear is using all the powers of his administration to sell Obamacare, marshaling millions of dollars for branding and market research, heartwarming television spots and eye-catching bus ads. A hired army of true believers have held meetings across the state, spreading the word and rebutting misconceptions.

The effort may be paying off, especially when compared to the problem-plagued HealthCare.gov national website. But for every Kentucky resident who has enrolled, there are tens of thousands like Cates who are logging on, but not signing up. As of Nov. 1, 32,485 people have successfully enrolled, according to state figures. That number is dwarfed by the more than 318,000 who have accessed the Kynect website, browsed without making an account and left without committing. Even more troublesome, nearly 14,000 in the first month did enough with the website to know they qualify for a subsidized plan, but have not signed up. Trust is still buffering.

SPREADING THE WORD

For more than three months, Cara Stewart, 32, has been driving her very dirty Toyota Prius all over Kentucky, holding seminars at libraries, bars, churches and meeting spaces to explain to anyone willing to listen why Kynect will benefit them. But after Kynect went online, the health law fellow and attorney with the Kentucky Equal Justice Center says she didn't expect to be finding residents who think Obamacare was repealed.

“It’s maybe Groundhog Dayish,” Stewart says, sounding a bit road weary. “[I’m] still hearing the same myths. I thought I would shift to doing a lot less community education and outreach by now.”

Instead, during Kynect’s fourth week in operation, Stewart keeps up her exhausting tour, traveling to Floyd County and then on to Leslie, Madison and Jackson counties, with a quick stop through Louisville on her way up to Northern Kentucky and the Cincinnati suburbs. She drove roughly 1,000 miles that week and ate too many Zaxby's chicken strips. It’s not unusual for Stewart to give lectures about Medicaid eligibility at fast-food drive-through windows.

Stewart expects more road work. Her November schedule looks just like her October schedule, which looked just like her September schedule. She says she is still getting the same volume of requests for presentations. At a recent session before a group of 30 students at a community college in Northern Kentucky, only one had enrolled. All the others, Stewart remembers, thought they weren't eligible.

At every one of her meetings, there are tiny epiphanies -- like the farmer who showed up in his work overalls convinced his rates were going to double, but walked away relieved that he actually qualified for Medicaid. It's enough, Stewart says, to keep her going.

"It seems worth it as soon as you have that moment," she explains. "It seems worth it to come home at 11. It seems worth it to have to find random places to stay. It seems worth it when you have that moment where someone's life is going to change."

The Beshear administration views the Affordable Care Act as potentially transformative for Kentucky, making the state healthier and more economically viable. A Beshear-commissioned study estimated the reforms would generate jobs and revenue. The governor is counting on progress to be steady. His administration has ballparked a goal of enrolling a third of the state's uninsured population within the first year.

To meet that goal, however, Stewart has found that the holdouts need face time with outreach workers like her. They need follow-up phone calls and visits. They need time to feel comfortable with the companies and the plans being offered, and they need reassurance from people they trust. They need Kynect to come to them.

BREAD AND BROCHURES

To help the hundreds of thousands of uninsured Kentuckians enroll in health care, the state has hired 622 “Kynectors,” advocates trained to work with residents directly. Many work part time. While $60 million has been spent on website construction and operations, according to state figures, $8.9 million has been budgeted for these workers. Many advocates, like Stewart, are not being paid by the state, but through nonprofits.

Christie Hartlage, a Louisville-based Kynector, reports that her staff of five has been receiving 40 to 50 calls a day from residents wanting help enrolling. She has appointments booked every day into the second week of November. “People are hungry for this program and they are looking for us,” Hartlage says.

In the early days of Kynect's launch, the Beshear administration caught on to the need, and sought to find creative ways to augment outreach. Lt. Gov. Jerry Abramson told HuffPost that a plan was adopted to have restaurant health inspectors pass out Kynect literature when they go on site visits. Hospitality workers in hotels and convention centers were also targeted for the Kynect push. “Most of those folks would want it,” Abramson says.

In the meantime, amateur Kynectors are filling the void, planning discussion events on their own, and utilizing very low-tech but effective word-of-mouth campaigns. A dentist's wife in Jackson County has started her own outreach. A special-needs teacher from Leslie County is passing out brochures to parents. These small efforts may turn out to be as consequential to Obamacare's credibility as a working website.

Kim Jenkins organized an event at her church in Georgetown for its congregation of 15. She put an ad in the local newspaper and found Stewart by calling a local legal aid nonprofit. After finally reaching Stewart, she convinced her to attend the event and lead the discussion.

“I do home health myself in Lexington,” Jenkins says. “I’m always seeing the needs in my hometown. I always look out for people. That’s my life God gave me, that’s my ministry.”

The Rev. Reginald Pullums says he thought Jenkins’ event was helpful. He has insurance, but his wife does not. “My wife has actually been on her job longer than I have,” he says. “She just doesn’t have health care. The health care that her job offers just isn’t affordable.”

Pullums wants at least one more Kynect session at his church, and plans to advertise the next one on his church bulletin board and through the "bread ministry," where community members hand out free bread.

crazy fox saloon

Inside the Crazy Fox Saloon

Carl Fox, 55, didn’t hesitate to open his Crazy Fox Saloon in Newport to Stewart. He’s had HIV for 28 years, is a 10-year cancer survivor, and was cured of hepatitis C by an experimental treatment. A degenerative disc disease sidelined Fox from steady work. Nine years ago, he could no longer afford health insurance and had to sell everything to qualify for Medicaid.

At the bar, he was given the title of honorary proprietor ("That's what my business card says") after selling the Crazy Fox to his husband. Whatever his title, Fox learned from his fight for health coverage. He made sure any bar employee who worked 20 hours or more a week got health insurance.

"All the sudden it hit me like a stone to the head, you lived in this fear, and yet your employees have no health insurance, nothing to fall back on," Fox recalls. "I saw the light."

With the new health care law, the light has brightened. So far, Fox has hosted three Kynect seminars at the Crazy Fox. He posted fliers near the box of free condoms. He listed the events on the bar's Facebook page. Stewart found out about the bar sessions when a mutual friend tagged her in a comment under the listing. She started answering questions in the comments, and then offered to help moderate the events.

The first session was for employees. The next two were for the bar’s regulars. Patrons could bring their laptops or use Fox’s to sign up. In the bar's dark "Godfather room," a few feet from the pool table and dartboards, Stewart and an outreach worker from nearby Ohio talked deductibles and dependents.

Fox says he feels he knows enough now to help people sign up. He has five more seminars set for November and December. He’s had to play mythbuster and counselor. And, now, unpaid Kynector. It's a role he transitions to, he says, every time he steps behind the bar.

“It’s daunting to some people,” Fox says. “To me, unfortunately, I’m an old hack at it. You have people that have never had the option because it wasn’t affordable. … Others have been in the system but have been kicked out. … Some can’t believe this."

If the website intimidated, and the new law agitated, the bar sessions eased fears and quieted tensions. Fox's credibility on the subject didn't hurt. He says he will start signing up patrons at the next session. “Anybody that wants insurance, I promised I would get them signed up,” he says.

A few miles away in Covington, the Pike Street Lounge was hosting its own health care seminars. That's where Chuck Garwitz, 63, found out he might be able to get a good deal on decent health insurance -- something he has had to go without since 1999. He lives on Social Security and a part-time job as an organist and choir director at a church. He had spent the year saving up for a set of dentures.

The next time he goes back to the lounge, Garwitz says he'll be looking to enroll in Kynect.

"I'm on limited income, and every bit that comes in goes right back out," Garwitz explains. "I'm going to have to see what fits my budget."

DAY ONE CRASH

“Would anyone show up?”

It was the night before Kynect’s big launch, and Chris Clark, the exchange technology program manager -- the man in charge of making the website function -- worried not that it would crash, but that no one would log on.

“If no one comes to use it, what’s the point?” Clark, 50, explains. “For me, that would have been the nightmare scenario if you will -- that we went to all this effort and all this work … and no one cared.”

While the Centers for Medicare and Medicaid Services apparently failed to adequately test the federal HealthCare.gov website, the agency did put Kynect through several rigorous checks. Clark says there were three preliminary design sessions with the agency, including a two-day site visit in March. Agency inspectors also visited for three days in August for an "operational readiness review," ordering up complex scenarios to see if the site could handle them.

“It was truly cool and exciting when we processed it in real time, determined eligibility and showed the results and got the right answers,” Clark recalls. “That gave us a very good confidence level that we were ready for operations.”

Kynect’s executive director, Carrie Banahan, joined Clark and about 60 tech staffers at Kynect’s command center, where she turned on the website the evening before Oct. 1. The staff projected the website onto a wall so everyone could watch. When it finally went live, the room broke into applause. A few hours later, at midnight, Kentuckians could start enrolling for health insurance.

As the sun came up, Banahan headed to Louisville to join Lt. Gov. Abramson at a college event kicking off Kynect. When Banahan checked her Blackberry at 8:30 a.m., she saw that 1,000 people had started applying. “I was like, ‘Oh my gosh,’” she told HuffPost.

Clark's fears proved unfounded. In fact, the crush of Kentuckians trying to log on slowed the site to barely a crawl the day it launched. Clark and his crew needed six hours to get the application process back up to speed. Since then, the site has held up. Any minor glitches have been quickly remedied.

“We didn’t anticipate what we saw on Tuesday,” Clark admits of the problems on launch day. “The good news is we were able to react quickly and take care of it.”

Even Clark has discovered that the true challenge facing Kynect isn't technical. It's personal.

A week after the website launched, Clark went for a haircut at a barbershop in Lexington. “How’s that Obamacare thing going?” the barber asked him. She told him about her middle-aged son, unable to work, unable to get insurance, because of a pre-existing condition.

Clark pulled out his phone and plugged in the details about the barber’s son on the Kynect website -- the county he lives in, his income, whether he has children. Clark determined that his barber's son qualified for Medicaid.

The barber was overjoyed. She insisted his haircut was on the house (Clark paid anyway). “She gave me a big hug and said I was an angel,” Clark says. “I think they lost all hope honestly. ... And I just very quickly was able to show them that in fact they do have options.”

SIGNING UP

During the first week after Kynect’s launch, Cates had gone far enough on the website that she was asked to call a phone number to verify her ID as part of the enrollment process. After being put on hold for 20 minutes, she gave up. About two weeks later, she attended one of Stewart’s sessions in a community meeting space one county over from her apartment in Berea. Stewart encouraged her to try again. She gave Cates her cellphone number.

"If you run into anything, let me know," Stewart told her. "Keep me updated on how it's going." This was motivation enough for Cates to try enrolling again.

After logging onto the website and being bewildered by her options, Cates and her husband thought she should ask somebody for help. Rodney Cates says he felt his wife’s frustration. “Every time she gets on there, she tries to find a plan,” he says. “They keep saying they have so many different choices, and when you get on there, they’re not there.”

Rodney Cates would just shake his head when his wife would start talking about Kynect. He believed his wife could not go without coverage. “There’s a history with her mom and stuff with breast cancer,” he says. “That really bothers me. It really weighs on my mind.”

Cates decided to track down a Kynector. It took a few days and three phone calls, but she arranged a meeting in her hometown.

The morning before Halloween, Cates met with a Kynector and settled on a plan. She signed up for the one operated by the Kentucky Health Cooperative, the nonprofit HMO she had not heard of before Kynect. The plan will cost her $17 a month, but comes with a $2,000 deductible. The Kynector hadn't heard of the cooperative either. So they Googled it. They discovered that all the hospitals in Cates' area would take the new insurance. There were several doctors in Berea who would accept the insurance as well. That was a deciding factor.

“I'm glad that I've done it and it's over with and I have it,” Cates says a few hours after signing up. “At the same time, it feels like, wow, $17 a month is nothing hardly. I've got insurance now.”

Her experience has also given her insight into what it really takes to enroll in health care -- not just to navigate a website, but to overcome fears and doubts and distrust.

Cates sent a text the following evening. “I applied to become a Kynector," she wrote.

HuffPost Readers: Did you receive a cancelation notice on your insurance? Email us here and send us a copy of the letter you received, or describe the details of your situation. Include a phone number if you're willing to be interviewed. Let us know if you want to remain anonymous.

Also on HuffPost:

Loading Slideshow...
  • Healthcare In America Is Already 'The Best In The World'

    One of the more positive sounding admonitions from health care reform opponents was that the United States had "the best health care in the world," so why would you mess with it? Well, it's true that if you want the experience the pinnacle of medical care, you come to the United States. And if you want the pinnacle of haute cuisine, you go to Per Se. If you want the pinnacle of commercial air travel, you get a first class seat on British Airways. Now, naturally, you wouldn't let just anyone mess with someone's tasting menu or state-of-the-art air-beds. But like anything that's "the best," the best health care in the world isn't for everybody. The costs are prohibitively high, the access is prohibitively exclusive, and the resources are prohibitively scarce. What do the people in America who "fly coach" in the health care system get? Well, at the time of the health care reform debate, they were participating in a system that was, by all objective measurements, <a href="http://www.huffingtonpost.com/2010/06/24/us-health-care-expensive_n_624248.html">overpriced and underperforming</a> -- if you were lucky enough to be participating in it. As anyone who's fortunate enough to have employer based health care or unfortunate enough to have a pre-existing condition can tell you, health care for ordinary people already involved all of those things that we were told would be a feature of the Affordable Care Act -- long waits, limited choice, and rationing. When the <a href="http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.aspx">Commonwealth Fund rated health care systems by nation</a>, the top marks in the surveyed categories went to the United Kingdom, New Zealand and the Netherlands. Ezra Klein examined the study, and <a href="http://voices.washingtonpost.com/ezra-klein/2010/06/us_health-care_system_still_ba.html">observed</a>: "The issue isn't just that we don't have universal health care. Our delivery system underperforms, too. 'Even when access and equity measures are not considered, the U.S. ranks behind most of the other countries on most measures. With the inclusion of primary care physician survey data in the analysis, it is apparent that the U.S. is lagging in adoption of national policies that promote primary care, quality improvement, and information technology.'"

  • Death Panels

    The only thing that perhaps matched the vastness of the spread or the depth of the traction of the "death panel" lie was the predictability that such a lie would come to be told in the first place. After all, this was a Democratic president trying to sell a new health care reform plan with the intention of opening access and reducing cost to millions of Americans who had gone without for so long. What's the best way to counter it? Tell everyone that millions of Americans would have increased access ... <i>to Death!</i> The best account of how the "death panel" myth was born into this world and spread like garbage across the landscape has been penned by Brendan Nyhan, who in 2010 wrote "Why the "Death Panel" Myth Wouldn't Die: Misinformation in the Health Care Reform Debate." <a href="http://www.dartmouth.edu/~nyhan/health-care-misinformation.pdf">You should go read the whole thing</a>. But to summarize, the lie began where many lies about health care reform begin -- with serial liar Betsy McCaughey, who in 1994 <a href="http://www.huffingtonpost.com/2009/10/07/andrew-sullivans-mccaughe_n_313157.html">polluted the pages of the New Republic</a> with a staggering pile of deception in an effort to scuttle President Bill Clinton's health care reform. As Nyhan documents, she re-emerged in 2009 when "she invented the false claim that the health care legislation in Congress would result in seniors being directed to 'end their life sooner.'" Nyhan: "McCaughey's statement was a reference to a provision in the Democratic health care bill that would have provided funding for an advanced care planning for Medicare recipients once every five years or more frequently if they become seriously ill. As independent fact-checkers showed (PolitiFact.com 2009b; FactCheck.org 2009a), her statement that these consultations would be mandatory was simply false--they would be entirely voluntary. Similarly, there is no evidence that Medicare patients would be pressured during these consultations to "do what's in society's best interest...and cut your life short." But the match that lit the death panel flame was not McCaughey, it was Sarah Palin, who repeated McCaughey's claims in a Facebook posting and invented the term "death panel." As Nyhan reports, Palin's claims were met with condemnation from independent observers and factcheckers, but the virality of the term "death panel" far outstripped its own debunking. To this day, the shorthand for this outrageous falsehood remains more firmly planted in the discourse than the truth. One thing worth pointing out is that Palin, in creating the term "death panel," <i>intended</i> to deceive people with it. In an interview with the <em>National Review</em>, <a href="http://www.nationalreview.com/articles/228636/rogue-record/rich-lowry">Palin admitted</a>: "The term I used to describe the panel making these decisions should not be taken literally." Rather, it was "a lot like when President Reagan used to refer to the Soviet Union as the 'evil empire.' He got his point across." Of course, while Reagan was exaggerating for effect, he wasn't trying to prey on the goodwill of those who were listening to him.

  • The Affordable Care Act Is A "Jobs-Killer"

    Naturally, the GOP greeted anything that the Obama White House did -- from regulating pollution to flossing after meals -- as something that would "kill jobs." The Affordable Care Act was no different. As you might recall, Republicans' first attempt at repeal came in the form of an inartfully named law called the "Repealing the Job-Killing Health Care Law Act." But did the health reform plan threaten jobs? Not by any honest measure. <a href="http://www.mcclatchydc.com/2011/01/17/106950/is-health-care-law-really-a-job.html">Per McClatchy Newspapers</a>: <blockquote>"The claim has no justification," said Micah Weinberg, a senior research fellow at the centrist New America Foundation's Health Policy Program. Since the law contains dual mandates that most individuals must obtain health insurance coverage and most employers must offer it by 2014, "the effect on employment is probably zero or close to it," said Amitabh Chandra, a professor of public policy at Harvard University.</blockquote> As McClatchy reported, the "job-killing" claim creatively used the "lie of omission" -- relying on "out of date" data or omitting "offsetting information that would weaken the argument." The Congressional Budget Office, playing it straight, deemed it essentially too premature to measure what the effect the bill would have on the labor market. At the time, Speaker John Boehner dismissed the CBO, saying, "CBO is entitled to their opinion." Perhaps, but lately, job growth in the health care industry has <a href="https://www.advisory.com/Daily-Briefing/2012/03/07/Jobs-report-preview" target="_hplink">bucked the economic downturn and health care has remained a robust sector of employment</a>. And it stands to reason that enrolling another 30 million Americans into health insurance will increase the demand for health care services and products, which in turn should trigger the creation of more jobs. Is there a downside? Sure. More demand, and greater labor costs, could push health care prices upward even as other effects of health reform push them down. But it's more likely that repealing the bill will have a negative impact on jobs than retaining it.

  • The Affordable Care Act Would Add To The Deficit

    The only thing more important than painting the Affordable Care Act as a certain killer of jobs was to paint it as a certain murderer of America's fiscal future. Surely this big government program was going to push indebtedness to such a height that our servitude to our future Chinese overlords was a <i>fait accompli</i>. <a href="http://www.huffingtonpost.com/2010/03/18/cbo-score-on-health-care_n_502543.html">As Ryan Grim reported in May of 2010</a>, the CBO disagreed: <blockquote>Comprehensive health care reform will cost the federal government $940 billion over a ten-year period, but will increase revenue and cut other costs by a greater amount, leading to a reduction of $138 billion in the federal deficit over the same period, according to an analysis by the Congressional Budget Office, a Democratic source tells HuffPost. It will cut the deficit by $1.2 trillion over the second ten year period. The source said it also extends Medicare's solvency by at least nine years and reduces the rate of its growth by 1.4 percent, while closing the doughnut hole for seniors, meaning there will no longer be a gap in coverage of medication.</blockquote> Recently, the CBO updated its ten-year estimate by dropping off the first two years of the law (where there was little to no implementation) and adding two years at the back end (during which time there would be full implementation). As you might imagine, replacing two years of low numbers with two years of higher numbers increased the ten-year estimate. But opponents of the bill immediately freaked out and declared the costs to have skyrocketed. <a href="http://nymag.com/daily/intel/2012/03/obamacare-haters-angered-by-facts.html">As Jonathan Chait reported</a>: <blockquote>The outcry was so widespread that the CBO took the unusual step of releasing a second update to explain to outraged conservatives that they were completely misreading the whole thing: "Some of the commentary on those reports has suggested that CBO and JCT have changed their estimates of the effects of the ACA to a significant degree. That's not our perspective. ... Although the latest projections extend the original ones by three years (corresponding to the shift in the regular ten-year projection period since the ACA was first being developed), the projections for each given year have changed little, on net, since March 2010." That is CBO-speak for: "Go home. You people are all crazy."</blockquote> As Chait goes on to note, the CBO now projects that "the law would reduce the deficit by slightly more than it had originally forecast."

  • The Affordable Care Act $500 Billion Cut From Medicare

    Normally, if you tell Republicans that you're going to cut $500 billion from Medicare, they will respond by saying, "Hooray, but could we make it <i>$700 billion</i>?" But the moment they got it into their heads that the Affordable Care Act would make that cut from Medicare, suddenly everyone from the party of ending Medicare As We Know It, Forever got all hot with concern about what would happen to these longstanding recipients of government health care. In fairness, <a href="http://www.factcheck.org/2010/03/a-final-weekend-of-whoppers/">as Factcheck pointed out</a>, the GOP opponents of Obama's plan were simply picking up a cudgel that had recently been wielded by the president himself: <blockquote>Whether these are "cuts" or much-needed "savings" depends on the political expedience of the moment, it seems. When Republican Sen. John McCain, then a presidential candidate, proposed similar reductions to pay for his health care plan, it was the Obama camp that attacked the Republican for cutting benefits.</blockquote> <a href="http://www.factcheck.org/2010/03/a-final-weekend-of-whoppers/">Nevertheless</a>! <blockquote>Whatever you want to call them, it's a $500 billion reduction in the growth of future spending over 10 years, not a slashing of the current Medicare budget or benefits. It's true that those who get their coverage through Medicare Advantage's private plans (about 22 percent of Medicare enrollees) would see fewer add-on benefits; the bill aims to reduce the heftier payments made by the government to Medicare Advantage plans, compared with regular fee-for-service Medicare.</blockquote> The <i>New England Journal of Medicine</i> <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMp1005588">concurred</a>: <blockquote>A phased elimination of the substantial overpayments to Medicare Advantage plans, which now enroll nearly 25% of Medicare beneficiaries, will produce an estimated $132 billion in savings over 10 years. [...] The ACA also produces nearly $200 billion in savings by assuming that providers can improve their productivity as firms in other industries have done. On the basis of this presumed improvement, the law reduces Medicare's annual "market basket" updates for most types of providers - a provision that has generated controversy.</blockquote> The law doesn't cut any customer benefits, just the amount that providers get paid. Hospitals and drug companies agreed to these cuts based on the calculation that more people with insurance meant more people consuming what they sell and, more importantly for the hospitals, fewer people getting treated and simply not paying for it.

  • The Affordable Care Act Provides Free Health Care For Undocumented Immigrants

    This lie was launched to prominence with the help of a false accuser, South Carolina Rep. Joe Wilson, who famously heckled President Barack Obama during an address to a Joint Session of Congress by yelling "You lie!" after the president had mentioned that undocumented immigrants would not be eligible for the credits for the bill's proposed health care exchanges. As Time's Michael Scherer pointed out, this was not much of a challenge for factcheckers: <blockquote>In the Senate Finance Committee's working framework for a health plan, which Obama's speech seemed most to mimic, there is the line, "No illegal immigrants will benefit from the health care tax credits." Similarly, the major health-care-reform bill to pass out of committee in the House, H.R. 3200, contains Section 246, which is called "NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS."</blockquote> In fact, <a href="http://voices.washingtonpost.com/ezra-klein/2010/04/why_immigrants_get_short_shrif.html">as Ezra Klein pointed out</a>, the Affordable Care Act "goes out of its way to exclude" undocumented immigrants: <blockquote>As the AP points out...there are about 7 million unauthorized immigrants who will be prohibited from buying insurance on the newly created exchanges, even if they pay out of their own pocket. And the exclusion of this group from health reform -- along with other restrictions that affect fully legal immigrants as well -- could create a massive coverage gap that puts a strain on the rest of the health system as well.</blockquote> Klein goes on to add that "immigrants-rights advocates tried to prevent this scenario from happening," but they ended up losing to the politics of the day. The concession they won was a promise from the president that he would shepherd a comprehensive immigration reform package through the legislature. They lost that round, too.

  • Republicans, And Their Ideas, Were Left Out Of The Bill And The Process

    Were health care policies dear to Republicans left out of the health care reform bill? Totally! <a href="http://thinkprogress.org/health/2009/10/29/171026/top-10-reasons-why-republicans-should-support-the-house-health-bill/">Unless we're counting the following</a>: --Deficit-neutral bill --Longterm cost reduction --Interstate competition that allows consumers to purchase insurance across state lines --Medical malpractice reform --High-risk pools --An extension of the time young people were allowed to remain on their parents' policies --No public money for abortion --Small business exemptions/tax credits --Job wellness programs --Delivery system reform In fact, the Democrats were eager to get GOP input and enthusiastic about including many of their desired components in the bill. Oh, and did we mention that the Affordable Care Act was modeled on a reform designed and implemented by a former Republican governor and presidential candidate, whose innovation was widely celebrated by the GOP while said former governor was running for president? And did we mention that the individual mandate that was used in Romneycare to ensure "no free riders" was originally dreamed up by the Heritage Foundation? And did we add that additional DNA of the Affordable Care Act was borrowed from the Senate GOP alternative to the Clinton plan in the 1990s and the <a href="http://www.bipartisanpolicy.org/news/press-releases/2009/08/bipartisan-policy-center-releases-report-improving-health-care-quality-a" target="_hplink">2009 Bipartisan Policy Committee plan</a>, which was endorsed by Tom Daschle, Howard Baker, and Bob Dole? As for the process, you might recall that the White House very patiently waited for the bipartisan Gang Of Six to weigh in with its own solution, and openly courted one Republican gang member, Sen. Chuck Grassley, long after it was clear to every reporter inside the Beltway that Grassley was intentionally acting in bad faith. And perhaps you don't recall the bipartisan health care summit that was held in March of 2009? if so, don't feel bad about it -- RNC Chairman Michael Steele couldn't remember it either, <a href="http://politicalcorrection.org/blog/201002250005">when he yelled at the president for not having one</a>.

  • The Demonization Of 'Deem And Pass'

    So, here's a fun little story about obscure parliamentary procedures. In May of 2010, as the health care reform michegas was steaming toward its endgame, it looked like the measure might fall. The Senate had passed a bill, but the House was stuck in a bit of a jam. It had no other choice but to take a vote on the Senate's bill, because if the House bill ended up in a conference committee to be reconciled with the Senate's, the whole resulting she-bang was assured of a filibuster, as the Democrats had, in the intervening period, lost their Senate supermajority. But the House had a problem. <a href="http://www.huffingtonpost.com/2010/03/16/health-care-opponents-dem_n_501353.html">As I wrote at the time</a>: <blockquote>House members are averse to doing anything that looks like they approve of the various side-deals that were made in the Senate -- like the so-called "Cornhusker Kickback." The House intends to remove those unpopular features in budget reconciliation, but if they pursue budget reconciliation on a standard legislative timeline -- where they pass the Senate bill outright first and then go back to pass a reconciliation package of fixes -- they'd still appear to be endorsing the sketchy side deals, and then the GOP would jump up and down on their heads. Enter "deem and pass." Under this process, the House will simply skip to approving the reconciliation fixes, and "deem" the Senate bill to be passed. By doing it this way, the Democrats get the Senate bill passed while simultaneously coming out against the unpopular features of the same.</blockquote> "Deem and pass" is the aforementioned obscure parliamentary procedure. And here's the thing about obscure parliamentary procedures -- everyone <i>loves</i> them when their side is doing them, but when they're being <i>done to you</i>, then they are basically evil schemes from the blasted plains of Hell. So if you're guessing that the Republicans declared the Democrats' use of "deem and pass" -- which also carried the moniker "the Slaughter Rule," after Rep. Louise Slaughter, who proposed its use in this instance -- to be a monstrous and unprecedented abuse of power, then give yourself a prize! And give yourself a bonus if you guessed that in reality, the GOP had used "deem and pass" <i>lots of times</i>. <a href="http://www.huffingtonpost.com/2010/03/16/house-has-long-history-of_n_500623.html">As Ryan Grim reported</a>, "deeming resolutions" had been in use dating back to 1933, and in 2005 and 2006, Republicans employed them 36 times. Other Republicans complained that Slaughter was supporting a tactic that she once vigorously opposed. <a href="http://voices.washingtonpost.com/ezra-klein/2010/03/the_arms_race_of_rules.html">That's true</a>! She fought the "deem and pass" during the Bush administration and lost. Which is precisely when she learned how effective it could be!

  • The Affordable Care Act Would Create A Mad Army of IRS Agents

    Lots of people wouldn't mind having better access to more affordable health care. But what if it came with thousands of IRS agents, picking through your stool sample? That sounds pretty bad. It also sounds pretty implausible! But that was no impediment to multiple health care reform opponents making claims that the tax man was COMMINAGETCHA! In this case, the individual mandate -- which requires people to purchase insurance or incur a tax penalty -- provided the fertile soil for this deception to spread. A March 2010 floor speech from a panicked Sen. John Ensign was typical of the genre: <blockquote>My amendment goes to the heart of one of the problems with this bill. There is an individual mandate that puts fines on people that can also attach civil penalties. And 16,500 new IRS agents are going to be required to be hired because of the health care reform bill.</blockquote> March of 2010 was a pretty great time for this particular lie. In one five day period, Ensign was joined by Reps. Paul Ryan ("There is an individual mandate. It mandates individuals purchase government-approved health insurance or face a fine to be collected by the IRS which will need $10 billion additional and 16,500 new IRS agents to police and enforce this mandate."), Pete Sessions ("16,000 new IRS agents will be hired simply to make sure that this health care bill is enforced.") and Cliff Stearns ("There is $10 billion to hire about 16,000 new IRS agents to enforce the individual mandate on every American"). All wrong! <a href="http://factcheck.org/2010/03/irs-expansion/">Per Factcheck</a>: <blockquote>This wildly inaccurate claim started as an inflated, partisan assertion that 16,500 new IRS employees might be required to administer the new law. That devolved quickly into a claim, made by some Republican lawmakers, that 16,500 IRS "agents" would be required. Republican Rep. Ron Paul of Texas even claimed in a televised interview that all 16,500 would be carrying guns. None of those claims is true. The IRS' main job under the new law isn't to enforce penalties. Its first task is to inform many small-business owners of a new tax credit that the new law grants them -- starting this year -- which will pay up to 35 percent of the employer's contribution toward their workers' health insurance. And in 2014 the IRS will also be administering additional subsidies -- in the form of refundable tax credits -- to help millions of low- and middle-income individuals buy health insurance. The law does make individuals subject to a tax, starting in 2014, if they fail to obtain health insurance coverage. But IRS Commissioner Douglas Shulman testified before a hearing of the House Ways and Means Committee March 25 that the IRS won't be auditing individuals to certify that they have obtained health insurance.</blockquote> As Factcheck goes on to note, <a href="http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf">on page 131 of the bill that was passed</a>, the IRS is explicitly prohibited from "from using the liens and levies commonly used to collect money owed by delinquent taxpayers, and rules out any criminal penalties for individuals who refuse to pay the tax or those who don't obtain coverage."

  • Affordable Care Act Bill Is Way Too Long And Impossible To Read!

    Oh, Congresscritters, the poor dears! So many bills to read and so little time -- between raising campaign cash at lush fundraisers and receiving marching orders from powerful corporate interests -- to actually read them all. <a href="http://www.washingtonmonthly.com/archives/individual/2009_08/019629.php">And this Affordable Care Act was a real humdinger of a long bill</a>. And long bills are bad because length implies complication and complication requires study and study implies some form of "work." So the proper thing to do is to mulch the entire print run of the bill and use it to power the boiler that heats the "sex dungeon" in the Longworth Office Building, the end! Actually, reading the bill is not that hard, despite the complaints. As the folks at <a href="http://computationallegalstudies.com/2009/11/08/facts-about-the-length-of-h-r-3962/">Computational Legal Studies were able to divine</a>: <blockquote>Those versed in the typesetting practices of the United States Congress know that the printed version of a bill contains a significant amount of whitespace including non-trivial space between lines, large headers and margins, an embedded table of contents, and large font. For example, consider page 12 of the printed version of H.R. 3962. This page contains fewer than 150 substantive words. We believe a simple page count vastly overstates the actual length of bill. Rather than use page counts, we counted the number of words contained in the bill and compared these counts to the number of words in the existing United States Code. In addition, we consider the number of text blocks in the bill -- where a text block is a unit of text under a section, subsection, clause, or sub-clause.</blockquote> <a href="http://www.huffingtonpost.com/2009/11/09/house-health-care-bill-ac_n_350810.html">As HuffPost noted in March of 2010</a>, "the total number of words in the House Health Reform Bill are 363,086," and when you throw out the words in the titles and tables of contents and whatnot, leaving only words that "impact substantive law," the word count drops to 234,812. "Harry Potter And the Order Of The Phoenix," a popular book read by small children, is 257,000 words long. (Although in fairness to Congress, the Affordable Care Act contains very few exciting accounts of Quidditch matches.)

  • The 2012ers Join The Fun

    We couldn't have a list of Affordable Care Act distortions without noting the ways some of your 2012ers have added to the canon. Herman Cain said that if the ACA had been implemented, <a href="http://thehill.com/blogs/healthwatch/politics-elections/177511-video-cain-if-obamacare-had-been-implemented-already-id-be-dead-">he'd be dead</a>. Not likely! The new law expands coverage so that uninsured individuals who face what Cain faced (cancer) have a better chance of getting coverage, and it restricts insurers from tossing cancer patients off the rolls based on their "pre-existing condition." But more to the point, Cain would have always been the wealthy guy who could afford to choose his doctor and pick the care he wanted. The Affordable Care Act doesn't prohibit wealthy people from spending money. Rick Santorum says that his daughter, who is diagnosed with a genetic disorder called trisomy 18 and who required special needs care, <a href="http://blogs.desmoinesregister.com/dmr/index.php/2011/04/25/santorum-more-disabled-people-will-be-denied-care-under-obamacare/">would be "denied care" under the Affordable Care Act</a>. Nope! Again, the law restricts insurers from throwing people with pre-existing conditions off their rolls. And for individuals under 19, that went into effect in September of 2010. Michele Bachmann believes that the Affordable Care Act would open "sex clinics" in public schools. This is Michele Bachmann we're talking about. <a href="http://www.huffingtonpost.com/2009/10/01/bachmann-sex-clinics-will_n_306292.html">Do you even need to ask</a>? And finally, Mitt Romney has said, as recently as March 5, that he never intended his CommonwealthCare reform to serve as a "model for the nation." "Very early on," he insisted, "we were asked -- is what you've done in Massachusetts something you would have the entire government do, the federal government do? I said no, from the very beginning." Unless "very early on" and "from the very beginning" mean something different from the conventional definition of those phrases, <a href="http://thinkprogress.org/health/2012/03/05/438044/romney-mandate-model-video/">Romney should augment his daily pharmaceutical intake with some memory-enhancing gingko biloba</a>.

  • So Many More To Choose From!

    Obviously, we did what we could to include as many of these lies and distortions as possible, but there's no way to include them all. If you're a completist, however, be sure to check out the <a href="http://www.thefrisky.com/2012-03-14/fact-or-fiction-obamacare%E2%80%99s-1-dollar-abortions/">Impossible Tale Of The One-Dollar Abortion</a>, the <a href="http://www.washingtonpost.com/wp-dyn/content/article/2011/02/09/AR2011020905682.html">Story of the State-Based Inflexibility That Wasn't</a>, <a href="http://politicalcorrection.org/factcheck/201101210006">The Curious Case of the Politically Connected Waivers</a> and <a href="http://www.minnpost.com/dc-dispatches/2011/03/michele-bachmanns-health-care-cover-charges-hard-fathom">Nancy Drew And The Hidden $105 Billion Expenditure</a>.