The Four-Headed Beast of Obamacare Implementation

Today is the third anniversary of the final House vote on the Patient Protection and Affordable Care Act of 2010. And the main noise you hear about that is from excited conservatives who are happily anticipating the “failure” of Obamacare, and think a campaign to repeal can become a fruitful partisan issue in 2014 or 2016.

A lot of this, of course, is just the usual hype. The negative public opinion findings about Obamacare have always been suspect in conservative hands, since a big chunk of those disapproving of the legislation actually favor a more aggressive government role in health care, and another big chunk just don’t like the sound of the individual mandate and actually support the key individual provisions of the law. And the inveterate Obamacare-haters are unwilling to acknowledge the positive things about the law’s implementation, particularly a sudden downward trend in health care inflation.

But health reform supporters should cut through the doom-saying and acknowledge three big problems with Obamacare implementation that are quite real.

The first and most obvious is the patchwork pattern of cooperation and obstruction–not to mention plain old politics and bureaucracy–being exhibited by the states. Aside from the hard-core conservative states that have decided to torpedo the Medicaid expansion that is a big part of Obamacare’s design, and their concomitant refusal to assist in the establishment of exchanges for the purchase of private insurance policies, there is the ongoing set of negotiations that could in a number of states result in the privatization of Medicaid insurance services, which in turn could boost costs.

The second problem is the immense confusion over Obamacare’s requirements and procedures, particularly among businesses worried about increased mandated costs.

The third problem, which is the subject of a very important article by Phillip Longman in the March-April issue of the Washington Monthly, is language embedded in ACA by Republicans and lobbyists for pharmaceutical and medical device companies that make the comparative effectiveness research on which Obamacare’s “cost-bending” assumptions rely virtually illegal. If Obamacare can best be understood as a scheme where better medical practices and more efficient insurance markets make a big expansion of coverage possible and affordable, then this is a huge time-bomb nestled into its heart.

And then there is the fourth problem which we are only beginning to comprehend: like any large and complex piece of legislation, Obamacare will inevitably require some “fixing” (preeminently a change in the design flaw highlighted by Longman) beyond the powers provided to the executive branch or the states. But given the configuration of forces in Congress, that will be virtually impossible; the same gridlock that prevents a repeal of Obamacare will prevent constructive measures to make it work better.

Conservative writer Ben Domenech, in a piece today gloating in advance over Obamacare’s perilous future, is at least honest about this problem:

The Repeal Coalition will continue to work to undermine it at every opportunity, and the nature of its passage means that there is no foreseeable avenue for the normal bipartisan fixes and tweaks to make a sweeping law work better. Instead, Republicans are likely to seize on every sad story as justification for dramatic changes – and in 2016, mount campaigns designed to replace the system in whole or in part with plenty of material to use in their cause.

Yep. So supporters of Obamacare need to get out of the habit of thinking that Obamacare’s a done deal that the president’s re-election entrenched beyond serious challenge.

Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.