Relax, GOP! You’ve Already Wounded Obamacare

Affordable Care Act navigator Nini Hadwen (R) works with Marta Aguirre as she shops for health insurance in Miami last week.
National Journal
Jill Lawrence
Oct. 16, 2013, 1 a.m.

Re­pub­lic­ans are hav­ing a bad month, but they should cheer up. Sure, con­ser­vat­ive law­makers have flamed out in dozens of at­tempts to de­fund, delay, re­peal and pick off pieces of the Af­ford­able Care Act, and the GOP has taken the brunt of voter out­rage over the shut­down pre­cip­it­ated by that cru­sade. Yet with a big as­sist from its gov­ernors, the party has already done dam­age to Obama­care in nu­mer­ous, pos­sibly pro­found ways.

Let’s start with the dis­astrous launch of the be­hemoth fed­er­al in­sur­ance ex­change run by the Health and Hu­man Ser­vices De­part­ment. Yes, Re­pub­lic­ans man­aged to di­vert at­ten­tion from that to their own com­edy of er­rors on Cap­it­ol Hill. But don’t for­get why the fed­er­al ex­change, health­care.gov, is so gi­gant­ic. It’s be­cause just 16 states and the Dis­trict of Columbia cre­ated or plan to cre­ate their own mar­ket­places. By con­trast, al­most all of the na­tion’s 30 Re­pub­lic­an gov­ernors took a pass on set­ting up ex­changes for their own states, punt­ing that task to the feds. That along with oth­er tac­tics and de­cisions amounts to what you might call the GOP Ef­fect — dam­age that’s in­dir­ect, of­ten un­co­ordin­ated, and pos­sibly at times un­in­ten­tion­al, but po­tent all the same.

For in­stance, some of the ini­tial prob­lems on the fed­er­al ex­change were due to heavy traffic. It would not have been as much of a bot­tle­neck had more gov­ernors cre­ated in­di­vidu­al state ex­changes. More ser­i­ous and con­tinu­ing prob­lems are due to mis­judg­ments and short­com­ings em­bed­ded in the fed­er­al web­site it­self, and the worst may be yet to come.

Micah Si­fry, cofounder of the tech­pres­id­ent.com web­site, says the com­pan­ies that end up win­ning big fed­er­al con­tracts — for in­stance, CGI Fed­er­al and ma­jor de­fense con­tract­ors — “are not known for their in­nov­at­ive or up-to-date tech­no­logy. They are known for their abil­ity to win con­tracts.” Polit­ic­al de­cisions by the Obama ad­min­is­tra­tion, such as re­quir­ing con­sumers to de­term­ine their sub­sidy eli­gib­il­ity be­fore they can shop and see rates, also may be factors in the on­line mess.

The 16 states that built their own sites have used a vari­ety of con­tract­ors and many of their mar­ket­places have launched more smoothly than the fed­er­al health­care.gov. The bot­tom line is that the pres­sure on the fed­er­al ex­change would have been far less and its design flaws would have af­fected many few­er people had, say, 20 more states set up their own ex­changes us­ing a vari­ety of con­tract­ors and ap­proaches.

There’s also a toll that comes from hav­ing to set up sys­tems to run or help run three dozen ex­changes. That took time that might have been spent pre­par­ing for a smooth­er open­ing. “The fed­er­al ex­change has to in­ter­act with health plans that are sub­mit­ting bids in 36 states, and also has to work out data agree­ments with how to handle in­form­a­tion flow with 36 dif­fer­ent Medi­caid agen­cies, and they’ve had to work out in­sur­ance over­sight with 36 state in­sur­ance de­part­ments,” says Alan Weil, ex­ec­ut­ive dir­ect­or of the Na­tion­al Academy for State Health Policy. “It’s a huge work­load that com­petes for re­sources with build­ing the ex­change func­tion­al­ity.”

Some of the states that left ex­changes to the fed­er­al gov­ern­ment have not put any or many re­sources to­ward sign­ing people up. Since the law de­pends on high en­roll­ments to broaden the risk pool and keep cov­er­age costs re­l­at­ively low, these gov­ernors may have helped cre­ate con­di­tions ripe for high­er rates and con­sumer back­lash against the law.

More back­lash could arise when un­fair as­pects of the law be­come fully ap­par­ent. Demo­crats wrote in­to the bill that people be­low a cer­tain in­come would qual­i­fy for a Medi­caid ex­pan­sion paid 100 per­cent by the fed­er­al gov­ern­ment for three years. But when con­ser­vat­ives on the Su­preme Court turned that in­to an op­tion rather than a re­quire­ment, most Re­pub­lic­an gov­ernors either chose not to do it or couldn’t get their le­gis­latures to agree to the ex­pan­sion. The up­shot is that low-in­come work­ing people will get sub­sidies on the ex­changes, but work­ers with even lower in­comes will be cut out of sub­sidies be­cause they qual­i­fy for Medi­caid cov­er­age their state has chosen not to of­fer. There’s go­ing to be an­ger and cri­ti­cism about this — the only ques­tion is wheth­er it will be dir­ec­ted at gov­ernors or the law it­self.

The Janu­ary 2010 spe­cial Sen­ate elec­tion in Mas­sachu­setts was an­oth­er pivotal mo­ment for the Af­ford­able Care Act. Re­pub­lic­an Scott Brown won in part by prom­ising to stop Obama­care. He did not suc­ceed at that. But his vic­tory did end the Demo­crats’ fili­buster-proof 60-vote ma­jor­ity and the pos­sib­il­ity of any changes or im­prove­ments in the bill. The Demo­crat­ic-con­trolled House had to simply ac­cept the Sen­ate bill if any­thing was go­ing to pass at all.

Among the House ideas that fell by the way­side: a sim­pler way for lar­ger busi­nesses to com­ply with the man­date to provide health in­sur­ance. “Rep­res­ent­at­ives in the House had what was prob­ably a bet­ter idea: to make em­ploy­ers de­vote a cer­tain per­cent­age of their payroll to health in­sur­ance, in­stead of do­ing it by the num­ber of full-time work­ers,” bioeth­i­cist and former White House ad­viser Ezekiel Emanuel wrote in The New York Times when what he called the “overly com­plic­ated” em­ploy­er man­date was post­poned for a year.

The up­shot has been a be­lea­guered busi­ness com­munity up in arms about the bur­dens of the law, a one-year delay in the em­ploy­er man­date, and end­less fod­der for an­ec­dotes about jobs cut, ex­pan­sions nixed, and health be­ne­fits dropped. That’s just one ex­ample of how im­plac­able GOP hos­til­ity to­ward Obama­care, and iron­clad res­ist­ance to mak­ing it work bet­ter, is pro­du­cing polit­ic­al di­vidends for Re­pub­lic­ans. And there’s more where that came from, if they can man­age to shift the fo­cus from their own dys­func­tion to the health care launch from hell.

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