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Obamacare Optimists Find Comfort in History at Their Peril Obamacare Optimists Find Comfort in History at Their Peril

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Obamacare Optimists Find Comfort in History at Their Peril

ACA supporters hope the law's path will match that of Medicare Part D, but political headwinds promise to get in the way.


Former President George W. Bush campaigned for Medicare Part D in much the same way President Obama currently is for the Affordable Care Act.(TIM SLOAN/AFP/Getty Images)

Seeking to soothe fears over the rocky rollout of the Affordable Care Act, the law's supporters have time and again drawn comparisons to Medicare Part D—another major health care initiative that eventually found its footing after a tough beginning.

Two months in, Obamacare's woes are comparable to those the prescription-drug program faced at the same age. But for all the supporters' soothing, there's a critical difference between today's health care law and the one that was young a decade ago: politics.


While both programs were passed primarily with the support of one party, the divide over Obamacare was sharper than was the battle over Medicare Part D. Three years later, that gulf is showing no signs of shrinking, and veterans of the Part D project say the political opposition will continue to haunt the law law going forward.

"Substance and politics have to coexist, for better or for worse," Tom Scully, administrator for the Centers for Medicare and Medicaid Services under George W. Bush and a main creator of the Part D program, told National Journal, noting that 15 or 16 Senate Democrats joined in the effort to pass Part D. "[Dem support] took some of the teeth out; it was nowhere near as partisan [as the ACA]."

Now a well-regarded, mainstream program, Medicare Part D was as unpopular as the Affordable Care Act when it first passed, and continued to be as it was implemented. Enrollment for the program began in Nov. 2005 and continued through May 2006, with a Dec. 31 deadline for coverage beginning Jan. 1.


Just two weeks before initial enrollment for the Affordable Care Act ends Dec. 23, and three weeks before coverage is set to begin Jan. 1, proponents of the law continue to point to the rocky initial implementation of the now-beloved program as evidence that the ACA will work out in the end as well.

And the similarities are clear. Both programs had website issues. Both had delays. Both had problems with call centers. Both had troubles with the data going to insurers. Both had limited initial enrollment.

"CMS hired more phone-line operators, worked on site, and added more capacity for site," said Jack Hoadley, research professor at the Health Policy Institute at Georgetown University, easily referring to either Part D or Obamacare. "All the things that needed to be done were addressed. Whether well or fast enough, it got better."

Only one-third of Medicare beneficiaries who voluntarily enrolled in Part D during the initial enrollment period signed up before coverage began on Jan. 1.


Enrollment numbers for the ACA through December won't be released until the middle of January, but they are on track to also be a small fraction of the 7 million the Congressional Budget Office has estimated to enroll during the full open enrollment period.

Scully says these similarities make Medicare Part D as good a parallel as there is, but argues it's still not really parallel.

"In some ways [Part D] was more difficult, because you were creating a benefit where you really had no benefit before," he says. "Plans already exist, so it's not as difficult to actually carry out [the ACA]. With Part D it was easier to enroll beneficiaries, but once they were enrolled it was more complicated."

These enrollment challenges did not exist to the same extent with Part D, because beneficiaries didn't pick their plans, they were auto-assigned. Most seniors had relatively low marginal costs, and premiums came out of their Social Security checks, so they hardly noticed, Scully says. "There was nowhere near as much economic impact right off the bat on people."

There was also far less opposition working to bring any challenges to light.

Although Part D was largely a Republican effort, Democrats joined in its implementation efforts after it was passed. "There was really great collaboration after we passed the bill," says Dennis Hastert, House speaker during the program's rollout. "Even Dems were going out to town meetings to sell it after it passed. There was a good national effort to educate seniors on what it was all about and get them involved."

In contrast, Republicans' attempts to dismantle the ACA began before its implementation, and continue now, three months in.

Republican state legislators' decisions not to run their own exchanges or expand Medicaid increased the burden on the federal government to implement the law, which by design relied more heavily on state involvement than Part D.

"There wasn't the same active resistance, negative ad campaigns, and statements from opponents [with Medicare Part D]," Hoadley said.

Yet despite the political challenges, the implementation of Part D indicates that the end result of success could be the same for the ACA.

"There's a general sense that [Part D] is a good, workable program," Hoadley said. "It was well into year two before we were fully there. That's a realistic expectation here too, though it may take longer given the politicization of this one."

Much to the chagrin of some of his fellow Republicans, Scully is also confident the ACA will ultimately be popular.

"Whether you agree policy-wise, [the ACA] is going to be popular," he says, noting that 62 percent of people will qualify for subsidies on the exchanges. "Will it be more painful? Yes. Will it take longer? Yes. Will it be popular? Yes." Scully says. "People love free stuff."

"But I bet it won't be before November," he says.

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