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.

ANNANDALE, UNITED STATES: US President George W. Bush (L) and Secretary of Labor Elaine Chow (R) talk with an Asian/Pacific audience about the Medicare Prescription Drug Coverage plan for seniors 12 April 2006 at Virginia Community College in Annandale, Virginia. AFP PHOTO / TIM SLOAN
National Journal
Sophie Novack
Dec. 10, 2013, midnight

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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