ObamaCare Clusterfuck: Ross Douhat pivots elegantly to... What, exactly?
Now that all the shutdown madness is behind us -- and I'd sure like to know who pulled Boehner's strings to stop it, not that I ever will -- the Republicans are pivoting to the ObamaCare rollout. Of course, they didn't exactly help themselves by driving it off the front pages, and worse, they managed to identify shutting down the government with the rollout's problems in people's minds, but Republicans are nothing if not energetic and persistent, so here we go. Douhat in today's Times (six fucking bucks, now taxed!):
If you had told me, months ago, that weeks after the health care law’s coverage expansion went into effect I would be writing about the problems its launch had exposed, I would have assumed I’d be writing about rate shock, rising premiums and the disappearance of many cheap insurance plans — basically, all the problems conservatives have worried will make Obamacare a ruinously expensive failure if they play out as we fear they might.
Well, as to rate shock and premiums, there was a lot of frothing and stamping but none of it was meaningful until the Exchanges actually launched and people could compare plans. (And even that comparison is not greatly meaningful until people know what services are actually delivered for the (co-paid and deductibled) price, taking into account in- and out-of-network coverage, doctors available, pharmaceuticals). Still anecdotal -- and how could it not be, given the sign-up numbers so far? -- but an RL friend on the Federal Exchange, 50s, married, one child, self-employed, went shopping on the Exchanges and on eHealthinsurance when the Exchanges were down, and concluded that the policy he would be able to buy would be better than CORBA, but not a lot. So, that's not exactly a shock, but I imagine to many it will be a disappointment. And the disapperance of not only cheap but also good insurance plans seems to be real, as corporations shove people onto the Exchanges, or onto defined contribution (rather than defined benefit) private exchanges.
I may be writing about those issues soon enough. But for now there is a more pressing subject: The online federal health care exchange, the heart of the Obamacare project, is such a rolling catastrophe that it may end up creating a major policy fiasco immediately rather than eventually.
We will know, I think, by the second week in November. (Again, I think the litmus test is Obama appointing a czar.) That's not very far away. It is true that I have failed to be cynical enough -- I made the call that the Exchanges would be a Clusterfuck, but even I didn't predict how few people would make it all the way through the process to signup -- but I still think that, at least in a public relations sense, the Exchanges will be perceived as a success because they must be -- losing the Exchanges domestically would be the equivalent of losing a carrier group, internationally -- and the "creative class" that is now the dominant media faction lean strongly to Obama and are invested in the perception of his success. Basically, Ezra Klein needs to be able to write a sentence like "Although the Federal Exchanges had a very rocky start, his "Tiger Team" of Silicon Valley wunderkinder pulled it out of its nosedive, and now insurance companies are reporting thousands of new applications a week." Or some such.
[I]t was hard to imagine the Obama White House botching the design and execution of its national health care exchange. Building Web sites, mastering the Internet — this is what Team Obama does!
It was indeed. Nobody I talked to outside the political class thought that the launch was going to be anything other than a failure; there were too many signs leaking out evident to anybody who's ever worked on website and/or any sort of large project. Slipped dates, shed requirements, and management mumbo-jumbo are never good signs. Nor is a late start and last-minute changes driven by management. But none of us predicted the precise modality of failure; that would have been like predicting whether the flaming wreckage of a car rolling down a mountainside would land upside down or rightside up. But I must admit that even I was shocked to find a bug immediately, shocked that people would have to try dozens of times even to get on site, shocked at a trickle of signups small enough to be manually processed two weeks into the signup period, and shocked that corrupt data (!!!!!) would be passed to the insurers (the 834s). Apparently, however, Obama's going to give a speech about the Exchanges on Monday. I'm sure it will be the greatest speech ever. If he appoints a Czar, they might as well delay the mandate by a year, because you can't fix a broken software project with a Czar.
Except this time Team Obama didn’t. Like the Bush administration in Iraq, the White House seems to have invaded the health insurance marketplace with woefully inadequate postinvasion planning, and let the occupation turn into a disaster of hack work and incompetence. Right now, the problems with the exchange Web site appear to be systemic — a mess on the front end, where people are supposed to shop for plans, and also a thicket at the back end, where insurers are supposed to process applications.
They are systemic indeed. But -- I argue -- the systemic problems are the result of architectural problems. It is the architecture that is the unbuffable turd, not the system.
The disaster can presumably be fixed.
But in what political timeframe?
As Cohn pointed out on Friday, many of the state-level exchanges are working better than the federal one, and somewhere there must be a tech-world David Petraeus capable of stabilizing HealthCare.gov. And the White House has some time to work with: weeks before the end-of-year enrollment rush, and months before the mandate’s penalty is supposed to be levied.
Ha ha. Neat set-up for the Czar concept with the Iraq metaphor, I must admit. Thing is, though, Obama's been his own Czar throughout -- all the architectural and systemic decisions that led to the current Clusterfuck were made by the White House, not by HHS or the contractors; this includes the fundamental choice not to adopt the simple, rugged, and proven single payer architecture, to the decision to delay publishing regulations until far to too late, to changing the application form late in the process. All White House decisions, taken at the politival level.
But if the fix-it effort moves too slowly, it’s possible to envision a worst-case scenario unfolding. If the Web site doesn’t work soon [in weeks], even liberals concede that the mandate would have to be delayed...
I love "even liberals," as if HeritageCare -> RomneyCare -> ObamaCare were a liberal project. Oh wait, he's right!
... because you can’t very well fine people for failing to buy a product they can’t access. And that combination — a hard-to-navigate online portal and no penalty for staying uninsured — could effectively discourage all but the most desperate customers from shopping, which in turn would create an unsustainably expensive insurance pool, driving prices up and driving people away, and potentially wrecking the entire individual insurance market in short order.
Showing, as Douthat cannot apparently see, that setting up a social insurance policy on actuarial lines is another unbuffable turd.
If this happens, there will be a lot of schadenfreude on the right at the spectacle of technocratic failure. But the wreck of the exchanges may actually be worse for conservative policy objectives than a more successful rollout would have been.
A new twist!
That’s because while conservatives think the Obamacare exchanges are overregulated and oversubsidized, they are actually closer to the right-of-center vision for health care reform than the Obamacare Medicaid expansion, which is happening no matter what transpires with Healthcare.gov. So if the exchanges fail and the Medicaid expansion takes effect (and, inevitably, becomes difficult to roll back), we’ll be left with an individual market that’s completely dysfunctional and a more socialized system over all.
Maybe this is what Krugman had been told when he wrote that column on "seeing the future" that is Medicaid.
In that scenario, the Democratic Party would probably end up pushing, not for the pipe dream of true single payer [Here completely agreeing with Democrats, liberals, "progressives," etc.], but for a further bottom-up/top-down socialization, in which Medicare is offered to 55- to 65-year-olds and Medicaid is eventually expanded even more.
One wonders whether some Democrat planted this idea...
Meanwhile, the task for serious conservative reformers [worst oxymoron I've heard in a long time] — already not the most politically effective bunch — might actually become harder, because they would have to explain how their plan to build an effective, exchange-based marketplace differed from the Obama White House’s exchange fiasco.
Can't be done. ObamaCare is RomneyCare is HeritageCare. There is no "effective, exchange-based marketplace" to be bad!
So while Republican politicians may be salivating over a potential Obamacare crisis, the conservative policy thinkers [another amazing oxymoron] I know are not. They’re hoping, as I’m hoping, that this isn’t as bad as it looks. The chance to say “I told you so” is always nice, but not if the price is a potentially irrecoverable disaster.
So taking Douthat for the new Broder -- sorry, Ezra! -- the following "ideas" are in play for buffing the ObamaCare turd:
1. A Marketplace Czar (break out the "surge" tropes!)
2. Delaying the mandate
3. Expanding Medicaid
4. Lowering Medicare eligibility.