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If only the sick and elderly sign up for ACA, it is bound to fail
Nov 15, 2013 - By Doyle McManus
One of these weeks, now that the Obama administration has recruited a SWAT team of computer whizzes, health care.gov will recover from its shambolic debut and turn into, well, just another website. After all, it's only a website, and websites can be fixed.
But that's when a far more interesting chapter in the life of Obamacare will begin. We're about to witness a massive experiment in federalism to see whether the Affordable Care Act can succeed in two very different kinds of states: those where governments are actively working to help the law succeed, and those where they're working to make it fail.
Fourteen states, almost all with Democratic governors, are running their own health insurance exchanges, and in many of those enrollment is already reported to be working just fine -- in New York, Kentucky and Washington, for example.
Meanwhile, 27 states, most with Republican governors, opted to back away from the Affordable Care Act and leave it to the federal government to run (these are the same governors who complain regularly about the "government takeover" of health care).
In Georgia, the state insurance commissioner, Ralph Hudgens, publicly declared that he intended to be an "obstructionist." Florida, Missouri and other states imposed regulations to make it harder for Obamacare to attract users. (The remaining nine states are implementing the law in active partnership with the federal government.)
As a logical proposition, the Affordable Care Act only has to work in one state to prove its doubters wrong. This is what inventors call "proof of concept": If Obamacare can make it in New York (or Kentucky or Washington), then it can make it anywhere.
Only it's not that simple, warns Elaine Kamarck, a former aide in the Clinton White House who's now at the Brookings Institution studying the management of the federal government.
Along with Sheila Burke, a former aide to former Sen. Bob Dole, R-Kan., Kamarck has written a "user's guide" for citizens who want to figure out whether Obamacare is working or not, and it's invaluable.
The first thing to realize, Kamarck warns, is that almost every assessment of Obamacare will be colored by partisanship, on both sides.
"In the short term, people will see what they want to see," she told me last week.
There's already a battle of anecdotes: At the White House last week, President Obama appeared with a lineup of grateful enrollees, while Fox News found victims of "sticker shock" -- higher insurance prices that may or may not be Obamacare's fault. That's going to continue, and the negative stories may have a bigger impact than the positive ones.
But even if the law works splendidly in some states, that doesn't mean the program is out of the woods. If other states continue to drag their feet and make it difficult for people to enroll, that will impose higher costs on the system as a whole, Kamarck warned.
"Even in places like Mississippi, people who want health care are going to find it, no matter what their governor tells them," she said. "But what does that do to the cost?"
The biggest danger to Obamacare all along, she noted, has been the problem of adverse selection. If it's hard to sign up, sick people will persist, but healthy people may stop trying. And if an insurance pool has too many sick people and too few healthy ones, its costs will increase, and premiums will go up.
At that point, it will be up to Congress to fix the problem by increasing federal subsidies, imposing cost controls on health providers or offering lower-cost, stripped-down insurance plans. But if Republicans remain devoted to repealing the law, they're not likely to work very hard to fix it -- unless consumers (and voters) have embraced the program by then.
And that's why the fiasco of the Health.gov website rollout matters. The website wasn't the final exam, but it was the first, visible test of whether the Obama administration could get a complex new program to work, and it flunked.
"There does seem to be a consistent problem in the Obama administration when it comes to implementation," Kamarck said. "Its expertise in governance has never gotten close to its expertise in campaigning."
Obama's White House staff, she noted, has been strong in political skills but weak in management skills. (And she's a Democrat.)
"When federal programs don't work well, and public confidence in the government drops, it's disastrous for Democrats," she noted.
Even if the website recovers, its more-than-wobbly launch has already deepened public skepticism about Obamacare and federal activism in general. A Washington Post-ABC News poll released last week found that most of those surveyed believed the website glitches reflected "broader problems in implementing the health care law."
"The Affordable Care Act is not just a website," Obama said last week. He's right. Once the website is fixed, his real problems may have only begun.
Editor's note: Doyle McManus is a columnist for The Los Angeles Times. Readers may send him e-mail at firstname.lastname@example.org.