The new stimulus bill has made tens of millions of Americans eligible to new health insurance subsidies. But many will have to wait for help: It will likely take a year for full emergency aid to reach people, due to website complications and other logistical issues.

President Biden presented the grants as a fulfillment of his campaign pledge to strengthen the Affordable Care Act. And for many uninsured Americans, the new program will offer free or inexpensive health plans that were previously unaffordable.

But the complex structure of the health law makes it difficult to reorganize insurance subsidies, let alone create a new program for the unemployed. The systems that distribute the benefits depend on government coders who update websites and marketers who help people understand new programs and go through various administrative steps to collect them.

“I don’t think there is enough Xanax for this,” said Jodi Ray, project manager at Florida Covering Kids and Families, which manages the state’s health law awareness efforts.

Memories of Healthcare.gov’s notoriously bumpy rollout in 2013 still lingers on the minds of those overseeing the new update. The debacle quickly became a punchline for late night television hosts, and political responsibility for a law that already divides.

Now, that’s a cautionary tale from a federal government website unprepared for a deluge of buyers.

“The technology is not self-executing – it takes work,” said Joel Ario, managing director of health consultancy firm Manatt and a former Obama administration official before the launch of Healthcare.gov. “It’s unfortunate when you’re trying to run a big program like this. “

The first stage of the federal upgrade is expected to be ready by April 1: Healthcare.gov, where people buy insurance in 36 states, will begin posting prices that reflect the new policy. For more than five million low-income Americans, health plans will be available without a monthly premium. For others who earn more, new discounts could be worth hundreds of dollars a month.

But getting those lower prices will take work: Americans who already have Obamacare insurance will have to go back to the website where they purchased their insurance; make sure they don’t want to change plans; and certify that they want the new, expanded tax credits. Those who don’t will continue to pay their current price. They are expected to eventually receive the additional funds in the form of a large refund with their 2021 taxes next spring.

People who purchased their own insurance elsewhere will need to cancel their current plan and switch to a qualifying plan.

“The main thing we tell people is, go back to Healthcare.gov, work with your browser, and update your app,” said Adam VanSpankeren, program director at Covering Wisconsin.

Another key part of the stimulus is providing free health plans with a generous set of benefits to Americans who received unemployment insurance this year. Although coverage will be retroactive to January 1, the new benefit will take months to implement and will not appear on Healthcare.gov until this summer. This schedule can require people to visit Healthcare.gov up to three times: once to enroll in a plan, then to get the new income-based grants, and again to get the special unemployment benefit once. that she is ready.

“We’re going to miss a lot of consumers by turning them back,” said Ms. Ray, project manager in Florida. “We don’t have enough resources and we don’t have a lot of time.

The Biden administration is at work develop a network of professionals like Ms. Ray to help people navigate the process after substantial budget cuts in the Trump years. And officials have already pledged $ 50 million in spending to advertise Obamacare insurance options to those who may not realize they’re eligible.

Marketing will focus on the availability of big discounts and free health plans for many Americans. But advocates outside the administration are pushing for this spending to be even greater in reaching and registering people.

The slow rollout of government assistance is in part a result of the technological challenge of updating Healthcare.gov, which is connected to a maze of federal systems to verify people’s residency, income and insurance choices. .

“It’s a stable platform now, so these aren’t difficult changes,” said Andy Slavitt, a White House health adviser who was recruited by the Obama administration in 2013 to help save the nation. original Healthcare.gov site.

But even relatively easy changes to such systems take weeks or months of coding and testing. Peter Lee, CEO of Covered California, which manages that state’s insurance market, said his website team initially told him updates would take until August. It has pushed back, and now the automatic subsidy updates will begin on April 12 – with unemployment benefits following this summer.

“I have been running Covered California for 10 years,” he said. “One of my biggest ‘Ahas’ is that great technology isn’t agile. “

The slowness also reflects a political debate within the administration on how the new benefits should become automatic. Since the subsidies for health insurance are structured in the form of tax credits, anyone who receives too little help this year will eventually get a refund at tax time.

If the Biden administration automatically increases people’s tax credits, some people could face a higher risk of a large tax bill. About 2.6 million Americans had to repay Obamacare excess subsidies in 2019, Internal Revenue Service data shows compiled by Charles Gaba.

The additional grants “are like a loan from the federal government,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms in Georgetown, who says she understands why some people are reluctant to let the grants reset automatically. “You could end up owing Uncle Sam a lot.”

Many states that operate their own markets have taken the opposite decision: they are automatically applying the new subsidies to provide economic aid more quickly during the pandemic. California, Massachusetts, Washington, and the District of Columbia will deploy the benefits this way.

“We want to make it as easy as possible for people to get this benefit,” said Mila Kofman, executive director of DC Health Link. “Right now, the impact of Covid has been so economically devastating. This is why I am the most anxious to get this out quickly.

Research suggests that the more complex social protection programs must access, eligible people are more likely will fall through the cracks.

“They could have done it automatically, and instead they’re asking people to go through the process, and I think politically it’s a huge miscalculation,” said Pamela Herd, professor of public policy at Georgetown, which studies the costs of administrative burdens. . Ms Herd said a simpler process would likely increase enrollment and also build political support for continuing the programs, which are temporary (new grants will expire at the end of 2022). People tend to hate programs that are nasty to use, even if they’re generous, she said.

Although the stimulus bill passed with overwhelming support from Democrats in Congress, a substantial portion of Democratic lawmakers would prefer a simpler, more universal path to broader health coverage. This month, a majority of House Democrats co-sponsored a bill create a “Medicare for All” system, which would automatically provide government health insurance to all Americans, without the current system of grants and registrations.

Some state officials who use Healthcare.gov have said they understand why the federal government is taking a more cautious approach, but would prefer faster roll-out of benefits.

“It’s a tough call, but I’m going with less of the burden on the consumer,” said Mandy Cohen, North Carolina health and human services secretary.

Yet many policymakers say the changes are powerful, even if there are short-term setbacks. Mr Lee said this moment was almost as important as the launch of the main Obamacare provisions in 2014. The Congressional Budget Office has valued policies will reduce the number of uninsured Americans by 1.3 million; he thinks it’s possible to insure a lot more Americans this year. “We are optimistic to a large extent,” he said.