Doomed From the Start

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<ul><li><p>7/27/2019 Doomed From the Start</p><p> 1/4</p><p>Doomed From the Start</p><p>Why Obamacare's Disastrous Rollout is No Surprise</p><p>Kimberly J. MorganKIMBERLY J. MORGAN is Associate Professor of Political Science and</p><p>International Affairs at George Washington University.</p><p>It would be an understatement to say that this months rollout of the</p><p>Affordable Care Act, U.S. President Barack Obamas initiative to ensure that</p><p>all Americans have access to health insurance, has not gone according to</p><p>plan. On October 1, the online insurance marketplaces that are the lynchpin</p><p>of Obamacare (as the law has colloquially become known) were opened for</p><p>business -- but it quickly became clear that they are not functioning properly.Computer malfunctions have prevented enrollment, consumers are frustrated,</p><p>and politicians and pundits are attacking Obama for the resultant train</p><p>wreck[1]. The problems are all the more embarrassing given that publicly</p><p>funded health-insurance programs are commonplace in most other countries.</p><p>But the fact that the White House is having trouble implementing Obamacare</p><p>also should not come as a particular surprise. It is not that the Obamaadministration is especially incompetent. Rather, the program it is charged</p><p>with executing is a complex public-private hybrid that has no real precedentelsewhere in the world. The blend is purely American: Policymakers in the</p><p>United States have a history of jerry-rigging complicated programs of this</p><p>sort precisely because they have little faith in government. The result is a</p><p>self-fulfilling prophecy that fuels only deeper public cynicism about the</p><p>welfare state.</p><p>Among the advanced industrialized countries there is no real parallel to</p><p>Obamacare. In part, that is because most countries established universal</p><p>health insurance long ago, some fairly gradually. By contrast, the UnitedStates is abruptly expanding coverage to millions -- probably around seven</p><p>million people will be purchasing insurance coverage through the new</p><p>exchanges by 2014. Even the closest precedents fall far short of this. In the</p><p>mid-1990s, Switzerland boosted health-insurance coverage to try to reach thefour percent of the population that was not yet covered. But that was in a</p></li><li><p>7/27/2019 Doomed From the Start</p><p> 2/4</p><p>country whose entire population was seven million. In 2006, the Netherlands</p><p>adopted a health-care system in which individuals could choose theircoverage from competing health plans. Yet, unlike in the United States,</p><p>virtually all individuals and their families were already covered, and the vast</p><p>majority opted to keep the plan they had.</p><p>The real source of Obamacares current problems lies in the laws</p><p>complexity. A straightforward way to assure coverage would have been to</p><p>extend an existing, well-worn program to more people. This is how most</p><p>other countries guarantee health insurance. In the British National HealthService, there is little that beneficiaries need to do in order to receive health</p><p>insurance, as all residentsare automatically entitled. Other countries rely on</p><p>private intermediaries that provide insurance -- nonprofit insurance funds in</p><p>Germany or Switzerland, for example, or a mix of proprietary and nonprofitinsurers in the Netherlands. Even in those instances, benefits packages and</p><p>entitlements are highly standardized, making these health-care systems</p><p>relatively uncomplicated from the standpoint of beneficiaries.</p><p>In the United States, political antipathy to government programs precludes</p><p>this kind of straightforward administrative solution. Faced with such hostility,</p><p>policymakers regularly rig up complex public-private, and often federal-state,</p><p>arrangements that are opaque to the public, difficult to administer, and</p><p>inefficient in their operation -- what Andrea Louise Campbell, a professor ofpolitical science at the Massachusetts Institute of Technology, and I describe</p><p>as aRube Goldberg welfare state[2] -- because of the complicated way inwhich it achieves even basic tasks -- and what the political scientist Steven</p><p>Teles aptly labels a kludgeocracy[3].</p><p>The Affordable Care Acts health-insurance exchanges exemplify the</p><p>labyrinthine quality of U.S. social policy. The first hurdle for consumers is</p><p>figuring out if they are eligible for the new benefits: Although anyone lacking</p><p>insurance can shop for it on the new health-insurance marketplaces, onlythose with incomes in a certain range are eligible for subsidies. The subsidies</p><p>vary by income. Those already enrolled in a government health program such</p><p>as Medicare do not need to buy coverage on the exchanges, a source of</p><p>confusion forsome seniors[4] who assumed they needed to shop for a new</p><p>plan, perhaps because they (understandably) mixed up the exchanges with the</p>;jsessionid=67F39CDE5BCF18090CF6CB0ACBFE2AD8?cc=us&amp;lang=en&amp;;jsessionid=67F39CDE5BCF18090CF6CB0ACBFE2AD8?cc=us&amp;lang=en&amp;;jsessionid=67F39CDE5BCF18090CF6CB0ACBFE2AD8?cc=us&amp;lang=en&amp;</li><li><p>7/27/2019 Doomed From the Start</p><p> 3/4</p><p>open enrollment period for the marketized versions of Medicare -- the</p><p>Medicare Advantage and the Part D drug plan.</p><p>The new health-insurance exchanges are also meant to help people find out if</p><p>their incomes are low enough to qualify for Medicaid, in which case they willget their insurance in a different fashion -- through the Medicaid program run</p><p>by the state where they reside. Yet because the Supreme Court overturned the</p><p>Affordable Care Acts mandate that states expand Medicaid, about half of the</p><p>state governments are refusing to do so. That means that eligibility standards</p><p>vary widely across the country. Thus, two people with the same poverty-lineincome in Arkansas and neighboring Mississippi will not be eligible for the</p><p>same health program: In Arkansas, the person will go on Medicaid, whereas</p><p>in Mississippi the person may choose to buy a plan on the health-insurance</p><p>exchange but would receive no subsidy for it.</p><p>The information systems underpinning the insurance marketplaces have to</p><p>mesh multiple government and private databases in order to determineeligibility, entitlement to benefits, and available plans. It is not surprising,</p><p>then, that the system has broken down in numerous instances. It also requires</p><p>considerable coordination between the federal government and the 50 states,</p><p>which are allowed to set up their own health-care exchanges. So far, only 17</p><p>states, including the District of Columbia, chose to manage their own</p><p>exchanges, while seven others entered into varying forms of federal-statepartnerships. Another 27 states left it up to the federal government to set up</p><p>the exchange, and it is the federal marketplace, which has received a veryhigh volume of visitors, that has had the most operational difficulties.</p><p>The burdens of implementing Obamacare were dumped on a federal agency -</p><p>- the Centers for Medicare and Medicaid Services -- that already oversees</p><p>enormous national programs on a limited budget. Although the agency</p><p>received some funding increases, it operates with less than one-tenth the</p><p>number of federal employees of the Social Security Administration. Thosewho are fearful that the agency would gain too much influence over U.S.</p><p>health care systematicallystarved it of resources[5]. Thus, much of its work</p><p>is outsourced to private contractors, whose performance is highly variable, as</p><p>the current problems in the health-insurance exchangesreveal[6].</p></li><li><p>7/27/2019 Doomed From the Start</p><p> 4/4</p><p>The larger irony here is that administering a complex public-private health-</p><p>care system often requires more government, not less. Yet the very sameimpulse that created this system also impairs the government agencies that</p><p>could effectively oversee it. The programs, as a result, are messy and</p><p>confusing. It should be no surprise that trust in government is so low.Obamacares early difficulties may provide an easy target for politicians, but</p><p>those politicians have only to look into the mirror to see who bears</p><p>responsibility.</p></li></ul>