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Sebelius survival guide

Here's what Obama's health secretary will have to account for when she's in the hot seat on Capitol Hill.
U.S. Secretary of Health and Human Services Kathleen Sebelius speaks during the opening plenary of the National Health Policy Conference organized by The AcademyHealth February 4, 2013 in Washington, DC. Sebelius spoke on the Obama Administration's...
U.S. Secretary of Health and Human Services Kathleen Sebelius speaks during the opening plenary of the National Health Policy Conference organized by The...

Health and Human Services Secretary Kathleen Sebelius heads to Capitol Hill Wednesday—and Republicans are drooling.

House Republicans had been calling for Barack Obama to boot Sebelius even before the health care law's website turned out to be a disaster and before news broke that millions of Americans won't get to keep their plans.  

Her performance in front of the House Energy and Commerce Committee will need to be top-flight to withstand the pressure coming from both parties. She's sure to be asked tough questions about the website, Americans being forced to buy better health care plans and what the administration knew about both. Some will be fair and some will be for show.  

Here are the biggest questions she's sure to face, where they come from and what she'll need to say to survive: 

Q: One the website: What did you know, and when did you know it?

A: It's still unclear how much Sebelius knew about potential problems with in advance of the website's launch. She admitted last week that more time for testing would have happened in an ideal world, but that "we did not have the luxury of that." But it still isn't clear whether she and other top agency officials suspected there were any problems ahead of time or whether they ignored red flags earlier in the process. (One contractor, QSSI, testified that it had notified government officials before launch of problems with  its portion of the site.) Sebelius has already said that Obama was not told about any problems ahead of time.

Sebelius will have to walk a fine line in denying that she knew there were problems, but also defend her leadership as adequate. 

Q: So who's to blame for this website, then? 

At the first Obamacare hearing in Congress post-rollout, federal contractors blamed the Centers for Medicare and Medicaid Services (CMS), which was responsible for overseeing the website's development and launch. Lawmakers forced the contractors to cough up a few names of CMS officials, but no one seemed to know exactly who was in charge of making the executive-level  decisions about the website's development, testing, and launch.

CMS already seems prepared to take the fall, saying on Monday that it was "taking full responsibility" for the website's problems. But both Republicans and Democrats have demanded that individuals be held accountable for the failings, and many won't be satisfieduntil heads roll.

If Sebelius decides to point fingers, she'll have to do it in a way that doesn't just look self-interested. If she names names, Congress will demand details. 

Q: How do we know the website will be fixed by next month, as you claim? 

If Sebelius didn't see problems the first time around, why should Congress trust her now? She'll have to have a convincing answer, filled with the kind of specifics that are going to satisfy anyone following the fiasco closely.

The Obama administration didn't do itself any favors with its initial reluctance to disclose exactly who is working to fix the site and what they're doing to fix it. We now know that QSSI, one of the private contractors, is helming the process, working with top Obama aide Jeffrey Zients. Daily press calls with CMS are meant to keep the public posted on the progress being made, but given the earlier troubles, there's still a lot of skepticism about whether the job will get done on time, and whether the remedy all that ails the law. 

And the White House is already cutting it close with the late November deadline: Millions of Americans whose plans are being dropped in 2014 because of new regulations will need to sign up for new insurance by December 15 if they want to avoid a coverage gap beginning January 1, 2014. It's unclear whether the White House has a contingency plan if there are still serious problems with the website come December.

Q: Obama told the public that if you like your insurance you can keep it. But hundreds of thousands of Americans are going to lose their insurance because of Obamacare. Was Obama lying? Or did he just not know? 

A: This is the latest controversy to flare up—and the confusion is understandable. The cancelled plans are a feature of Obamacare, not a bug, so Obama never should have promised that everyone would get to keep his or her insurance—at least without adding a lot of qualifying statements. 

Administration officials have tried to push back by saying it's the insurers who are deciding to cancel these plans. But the reason these plans are going away is because they don't meet Obamacare's new standards for individual and small group health coverage, which require essential benefits like prenatal and drug coverage. Obamacare's insurance exchanges are meant to provide these Americans with viable alternatives to their cancelled coverage, giving them subsidies if they are under 400 percent of the poverty line (annual income under $43,320 for individuals).

But this leaves Sebelius in a vulnerable position. If the White House was willing to make such a mistatement over and over, why should they be trusted now? Sebelius will again need to lean on specifics and not generalities to survive this question. 

Q: Shouldn't we consider delaying the individual mandate, given the problems the site facing?

A: It's the single biggest question that Republicans have been pushing since the website's troubles have begun, joined by a handful of moderate Democrats like Sen. Joe Manchin, and they'll certaintly try to put Sebelius on the defensive.

Starting in January 2014, those who fail to have insurance for three consecutive months—lacking coverage for at least one day in each of those months—will pay a penalty when they file their 2014 tax returns. While the individual mandate officially takes effect on January 1, 2014, people will have until March 31 to sign up for insurance coverage without penalty—a grace period that the White House clarified last week. 

The exchanges are meant to provide affordable coverage for who don't receive employer-based insurance and don't qualifiy for Medicare or Medicaid. If the problems with the website persist, the thinking goes, is it reasonable to penalize uninsured Americans who can't easily purchase the product they're legally required to have? The White House hasn't given a straight answer yet.

Q: What about delaying open enrollment, as ten Democratic senators have already asked for?"

A: This is a more incremental change that would let Americans shop for insurance on the exchanges beyond March 31, when the 2014 open enrollment period is scheduled to close. Expect both Republicans and Democrats to ask Sebelius what the harm would be in doing so.

Larry Levitt, a senior adviser at the Kaiser Family Foundation, says it's not an easy decision to make. "On the one hand, it creates a risk that some people will choose to wait to buy insurance until they are sick. The whole point of having a limited open enrollment period is to avoid that," he told MSNBC. At the same time, "extending open enrollment could provide extra time to reach the so-called young invincibles" if they are still sitting on the fence in a few months' time.

From Levitt's point of view, there's no need to make that call right now, as we're still a ways from March 31. Austin Frakt, Boston University health economist, agrees. "I'd only extend open enrollment if the site's problems extended into the new year, and then I'd extend it by the amount of the new year for which there were problems," he says. The House committee will push Sebelius to give a straight up or down answer.

Q: Won't premiums skyrocket if not enough healthy people sign up for insurance?

A: This is probably the single biggest threat to Obamacare—and the reason that the website problems are such a big deal. The entire success of Obamacare hinges on expanding the risk pool to include more young and healthy people. That's what will offset the cost of the new requirements for all insurers to cover Americans with pre-existing conditions and provide services like prenatal coverage. 

If only old and sick people enroll, then premiums are bound to spike and insurers may drop out of the exchanges altogether—a chain reaction that insurers call "the death spiral." There are built-in protections like premiums subsidies to make insurance more affordable for lower-income families; and a reinsurance fee and "risk corridor" to help out insurers in case there aren't enough health enrollees. But the most critical part to expanding the insurance pool is the individual mandate. That's why Sebelius isn't likely to budge on the issue, but she will have to provide more reasons to believe that Obamacare enrollment will succeed.

Q: How many people have signed up already, and why haven't all these figures been made public?

A: Since enrollment is key to health reform's success, the sign-up numbers are a critical indicator. But the White House hasn't been very forthcoming with the overall numbers. The administration told the AP last week that 476,000 Obamacare applications have been started, but it's not clear how many will be finished.

The White House says that it will release official enrollment numbers in November, and Massachusetts' own health exchange suggests that the early weeks of sign-ups aren't representative. but Sebelius will be pressed for more specifics—and confronted with low enrollment figures in states like South Dakota, where officials report that only 23 people have signed up through the exchanges so far. 

But here, again, Sebelius will have a tough morning if she can't provide concrete details. Even some Democrats will find it hard to believe the administration simply doesn't know. 

Q: How can the public have confidence in Obamacare when the big launch has been such a failure?

A: Like other Democrats in the hot seat, Sebelius will face a tricky balancing act throughout her hearing: Making the case for Obamacare's eventual success without dismissing the very serious problems in its rollout. There are a few legitimate bright spots she will be able to point to: Enrollment in some states has been extremely robust, and the public is growing increasingly interested in Obamacare, despite all of the negative press.