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
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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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