The Optimist’s Case For Obamacare Implementation

Are you worried by all the baleful predictions being made by critics of the Affordable Care Act about how its implementation will proceed? It’s hard not to worry. Sure, you can dismiss a lot of the conservative talk of a “disaster” or “fiasco” as just spin from the usual suspects, based ultimately on the claim that a move in the direction of the universal health coverage found in most other countries is somehow unsuitable or unworkable for Americans. But precisely because Obamacare builds on the current crazy quilt of public and private insurance offerings, not to mention state regulations and a wide array of providers, and makes certain rebuttable assumptions about the behavior of markets and of millions of people, there is some inevitable suspense about how it will work out, especially in the short term when opponents of health reform are in a position to do significant sabotage work while obstructing legislation to fine-tune the law.

At TNR, Jonathan Cohn helps sort out the scare tactics and agitprop from the areas of reasonable concern, and offers a sort of optimist’s case for why Obamacare implementation may go more smoothly than many now predict, and why a lot of the negative expectations miss important parts of the story.

For one thing, he notes, Obamacare won’t immediately change the situation for the fortunate Americans with decent existing insurance:

[T]he vast majority of Americans won’t notice any of these changes directly, because they will continue to get insurance the same way they do today—through Medicare, through Medicaid, or through an employer. To the extent Obamacare affects these people in the short term, it will mostly be by adding protections such as prohibitions on lifetime limits or, in the case of seniors, extra prescription drug coverage. And those changes have already started taking effect….

Notice that the worries about implementation chaos apply strictly to people who would otherwise be uninsured or at the mercy of the existing individual insurance market, in which plans are inconsistently priced, full of coverage holes, and of unpredictable reliability—and in which financial assistance for buying private coverage is not available at all. Even if it takes these people a while to get insurance, and even if finding that coverage is a maddening experience, they’re going to end up with something they don’t have now: Coverage that meets more of their needs and is available to them, with substantial financial assistance. Don’t forget: Today, people with pre-existing medical conditions frequently cannot get any coverage on the individual market.

In other words, in focusing on the “shambolic messiness” of the transition to a new system, it’s important not to forget that the status quo is even messier, not to mention fundamentally unjust.

Some of the “sticker shock” stories we are already hearing about the effect of Obamacare on health insurance premiums have taken isolated incidents out of context (particularly the CareFirst premium increase request in Maryland that hasn’t been approved by state regulators), don’t account for the counter-evidence of a significant slowing in health care inflation, and most importantly, don’t reflect the new tax credits that will offset premium increases for most middle-class consumers.

Finally, notes Cohn, any major change in the health care system is going to produce short-term confusion and dislocations that tend to abate once people begin to become better informed:

The last time government introduced a major new health care program was in 2006, when Medicare began offering a prescription drug benefit through what is called “Part D.” It got off to a notoriously rough start, as seniors showed up at pharmacies only to discover they were enrolled in the wrong plans—or that their plans didn’t cover drugs like they did before. The Children’s Health Insurance Program, which became law in the late 1990s, was slow to attract enrollees. But things got better. As Larry Levitt of the Kaiser Family Foundation noted recently, the end result was that seniors got drug coverage and kids got insurance they never had before. Today, the programs are highly popular, even if they are not perfect.

Things will also get better if and when Republicans at the federal and state levels stop trying to destroy or repeal Obamacare, and begin operating within its basic framework, as some conservative health wonks and political strategists are already recommending. At that point, too, we can begin to look at serious problems with the new system instead of dealing with myths and alarms promoted by people who haven’t been right about much of anything.

UPDATE: At Eschaton, Atrios comments: “Even if the legislation does genuinely improve the system overall, it’ll still be a horrible system. A horrible system known as Obamacare.” Even if you agree entirely (and most progressives agree at least in part, which I why I talked about the problem of Obamacare building on rather than replacing the status quo ante), what are you going to do about it? Hope it all crashes and start over with a drive for single payer in hopes of another Democratic landslide of the sort that narrowly make Obamacare achievable? Fight for incremental improvements that not only make Obamacare work but deal with some of the underlying problems it didn’t address? With all due respect to those many progressives who think accepting a private insurance model (or at least not including a strong “public option”) doomed the Affordable Care Act to limited success or even failure. But that perspective doesn’t much indicate a specific road ahead.

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.