Monday, November 18, 2013

Obama and the Obamacare rollout

I found myself liking this column by Bob Kuttner and being annoyed by it at the same time: Obama's Gift to the Republicans Huffington Post 11/17/2013. I'm not quite sure what annoyed me. Part of it may have been the pop psychology. And there seems to be a sour-grapes edge to his criticism, suggesting that the whole problem goes back to trying to do anything more complex than what he calls "Medicare for All," a single-payer system.

But this observation is accurate as far as it goes: "The Affordable Care Act, as a government mandate for people to purchase private insurance with an array of possible subsidies, had too many moving parts. It was an accident waiting to happen."

However, there were particular features about this law that made it more politically accident-prone than a system structured this way had to be. Just including a public option would have made a dramatic difference, although it would have ramped up Republican fury even higher, if that's possible. The ACA delayed the main implementation until 2014, which would have given a Republican President elected in 2012 plenty of time to abolish it before the most popular features took effect.

And Kuttner's right about the complexity. It involves a sliding-scale subsidy option, online insurance exchanges, a range of new choices, new rules on health insurance, and it does rely on private insurance companies without the competition of a public option. The insurance companies get a definite benefit from the required coverage. But they don't have a profit incentive to make the Obama Administration or the federal government look good in the process of implementing them. The extension Obama is giving them on meeting minimum standards is potentially a sweet deal financially: the companies can still sell overpriced policies (at least renewals) that are junk insurance, or close to junk status, constructed in a way that they are unlikely to ever have to pay for any significant amount of medical care, e.g., policies that don't cover hospitalization costs.

And I agree with Kuttner that, "The president has lost control of both the narrative and the politics."

But he also seems to some extent to be buying into the position that the ACA is just an unworkable thing: "The Republicans, who were unable to destroy Obamacare by holding the budget hostage, are now enjoying watching it fall of its own weight."

I'm not sure what the falling-of-its-own-weight metaphor means there. The website is having some problems. And I tend to think Kuttner is probably right in saying:

This law, after all, is Obama's signature initiative. It has been on the books since March 2010, with a full implementation date of 2014. An engaged chief executive would have been demanding frequent and detailed progress reports from his team. He would have gotten early warnings about possible glitches. But this president is tragically and inexcusably hands-off.
Obama really did need to have a good rollout. And when the rollout hit some problems, he needed needed to double-down on defending the program, not scramble to find ways to apologize and re-apologize and compromise with the critics on minimum insurance standards.

A public option would have made a huge difference. But Democratic critics who feel they need to distance themselves from "Obamacare" should be proposing that as a fix, not undermining the ACA system even more. Mark Shields in Friday night's Political Wrap on the PBS Newshour had reverted back to his now-customary half-asleep state after several weeks of being energized and focused. But even though he carelessly overstates it, he also has a point when he says (Shields and Brooks on waning ACA confidence and its impact on liberal government 11/15/2013):

Judy, this is beyond the Obama administration. If this goes down, if the Obama -- if health care, the Affordable Care Act is deemed a failure, this is the end -- I really mean it -- of liberal government, in the sense of any sense that government as an instrument of social justice, an engine of economic progress, which is what divides Democrats from Republicans -- that's what Democrats believe.

And that's what Democrats believe. Time and again, social programs have made the difference in this country. The public confidence in that will be so depleted, so diminished, that I really think the change -- the equation of American politics changes.
It won't be the end. But it will be a huge setback. And, as we saw last week, the Democrats still have a tendency to react to setbacks by trying to look more "centrist" instead of articulating a liberal alternative like a public option that would let them both defend the basic idea of the ACA and also show they are responding to public criticism. In this case, a public criticism massively magnified by the mainstream press.

Shields at least sees the urgency in defending the ACA. But he went along with the crowd in piling in on Obama over the keep-your-own-health-insurance thing - understandably, I guess, since Obama himself isn't defending himself on it:

The other thing is, let's be very blunt about it. The president said time and again that nobody is going to lose his insurance or her insurance if they like it. And so, driven to one of two conclusions, that is -- wasn't a true statement. And you're driven to one of two conclusions.

Either the president was almost -- almost negligently uncurious in not asking about what the answer was, or he made the choice to trade his considerable reputation and record of integrity for short-term political gain. That's why they had to come and that's why there was such consternation in the ranks.
In retrospect, Obama should have tacked on some qualifier to that statement, like "but this is a private-insurance based plan, so every consumer will have choices to make. If my insurance company starts charging me more for the same or less services, do I stick with them or do I make a more suitable selection from the insurance exchanges?" That would have combined the reassurance about keeping your own insurance with a qualification and bit of explanation about how the new system would work.

But the basic statement was fair. Even junk insurance plans that were in effect at the time the ACA was passed in 2010 were grandfathered in. But Obama never promised your insurance company would never raise rates. On the contrary, it was a selling point for the ACA that it was based on private insurance. Rates were going to be subject to private competition, facilitated by the new exchanges. The point of the particular approach in the ACA was to create a functioning competitive market in insurance that would make it accessible to everyone. Obama tried at one point to defend himself from the criticism by responding along those lines. But then his seeming compulsion to accept Republicans framing kicked in to the point of effectively accepting the harshest Republican criticism on the keeping-your-insurance issue. So now he has commentators like Shields, who is obviously inclined to defend him on the ACA, not only saying it was false but joining Republicans in trashing Obama's "record of integrity" over the issue.

Digby has a helpful discussion of the problems of the Obamacare website in The Contractor State Hullabaloo 11/14/2013. She links to this piece by David Auerbach, Quixotic Queries Question Quality! Slate 10/12/2013, which shows something about the complexity of the project management involved. It's not an excuse. But it provides real-world context.

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