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ACA enrollment: Lessons from Social Security and Medicare

People signing up for healthcare at an ACA exchange enrollment center in New Haven, NJ. 

We’re coming up on two months since the government started signing folks up for the new Obamacare health exchanges, and let’s just say it hasn’t been the smoothest rollout in American history. If you look back a bit, there are a few times the government has pretty successfully managed to enroll a huge number of people. Like Social Security, and Medicare. So what’s so different this time?

First of all, and most obviously, this time it’s all about the website. In the fall of 1936, when the government wanted to get everybody over 65 to sign up for Social Security, the only way to connect with them was the Postal Service.

Then, they invented a whole new system to identify all of us – the social security number. Everyone’s information was stored in a cavernous warehouse in Baltimore.

“They had, you know, millions and millions of pieces of paper and numbers to keep track of, but they had people to do it, they had enough expertise to do it,” says Ed Berkowitz is a history professor George Washington University. “I don’t think we quite have that luxury today in terms of manpower because the government is very constrained in its operations.”

Also, it was easier to identify everyone who was over 65. With healthcare today, it’s tricky to figure out which Americans don’t have insurance. For Social Security, you didn’t get a choice – it was law and you had to sign up. 30 years later, signing people up for Medicare was a little more complicated. But still way simpler than Obamacare is. Ted Marmor is an emeritus professor at Yale who was part of the government team that rolled out Medicare.

“It’s easy to make the case to an older American in 1966, ‘you know what, you’ve got hospital insurance now that you’ve already paid for,’” says Marmor. “And this is going to be done under the auspices of the Social Security Administration, in which there was considerable public trust.”

The Social Security Administration used the whole apparatus they’d built over the previous 30 years to construct the new Medicare program. There were leaders who were experienced, everybody knew what their job was, and Marmor says there was a clear chain of command.

 “Now just contrast that with the apparatus since March of 2010 and now. Do you have any comparable sense of that?” asks Marmor. “No, you don’t because it isn’t here.”

During the Medicare rollout, there were Social Security offices all over the country that people could just walk into and ask a question. We actually do have something like that today. Problem is, there’s just two.  And they’re both in Connecticut.

Officials at the Connecticut healthcare exchange say the enrollment centers in New Haven and New Britain are the only storefront locations in the country specifically for helping people enroll in Obamacare. Sure, around the country there are navigators and application counselors. You can call them up or find them at health fairs. But Ted Marmor says it’s not the same as having a well established location in every town, like the Social Security offices back in the day.

For Jermaine Monk, who came to sign up at the New Haven enrollment center, the hardest part was creating a password that had enough numbers and symbols to satisfy the state’s website.

“I think it worked fine,” says Monk. “It actually didn’t take as long as I thought. I thought it would take maybe four hours or something.”

Of course, it’s not as easy other places, especially in states that aren’t as on board with the whole exchange thing. Jonathan Oberlander, who’s a health policy professor UNC Chapel Hill, says that’s a key difference between the Obamacare rollout and the big ones of yesteryear. Social Security and Medicare were federal programs through and through.

“And one of the Achilles Heels in Obamacare is that its success depends on the cooperation of states that want the law to fail,” says Oberlander.

He says as much as the current rollout has been bungled, when you compare it to Social Security and Medicare, this one was just a lot harder from the beginning.

About the author

Craig LeMoult is a news reporter for National Public Radio member-station WSHU in Fairfield, Conn.
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