Political Animal


March 22, 2013 10:11 AM The Four-Headed Beast of Obamacare Implementation

By Ed Kilgore

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 is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute. Find him on Twitter: @ed_kilgore.


  • Josef K on March 22, 2013 10:39 AM:

    Its pretty much a give that, absent a complete repeal, the ACA is here to stay. That said, a Republican administration in 2016 will doubtless do what they can to gum up the works of implementation and reduce public support for it as much as humanly possible.

    Same old, same old.

    I wonder if Winston Churchill isn't watching this from somewhere and revising his opinion of democracy as the 'least worst system of government'?

  • T2 on March 22, 2013 10:44 AM:

    Obama must not succeed at anything. That is and has been the GOP mantra since inauguration day over four years ago. Why? pretty obvious (hint: it's not because he's a Democrat).

  • c u n d gulag on March 22, 2013 10:49 AM:

    May I repectfully suggest that the GOP change it's name and acronym, from the "Grand Old Party" and "GOP," to "SANS" - Sociopathic Nihilists, Anarchists, and Saboteurs.

    After all, there's nothing "grand" about their "party" for the "old" - and, besides, they do want to live SANS any form of meaningful government, don't they?.

  • John on March 22, 2013 11:08 AM:

    It'll be a lot harder for them to repeal it once the popular parts start going into effect.

  • Rick B on March 22, 2013 11:52 AM:

    The current conservative Republicans are, in my opinion, the surviving members of what used to be America's dominant ruling white race. They have spent their entire lives seeing the lesser breeds ("Minorities" is the shorthand description) step in and take over government functions and American society which they are not qualified to deal with.

    That's what they mean when they say America is in decline. They think America would still dominate the world as it did in 1945 if the "right people" were still in charge and the government was not interfering with business (tobacco sales, giving jobs to the "right people" rather than women, Blacks or Hispanics, trying to reduce the sale of sugar water, etc.)

    "Obamacare" is one big signal to them of everything that is wrong with America today. It's not a rational argument. It's pure fear, so no rational arguments will change them.

  • Sgt. Gym Bunny on March 22, 2013 12:02 PM:

    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.

    Somehow, I kinda doubt the GOTea has any intentions of replacing Obamacare with anything. I'm having a hard time thinking of alternative policies they could use to replace the GOP-Lite policies that are already in Obama/RomneyCare.

    Unless they really do think "death panels" actually are an efficient and cost-saving way to manage health insurance for us lowly, undeserving, brown muckity muck mucks.

  • Peter C on March 22, 2013 12:45 PM:

    OK,so we're going to have to fight. We may as well fight hard!

    I'm not sure that Obamacare will work really well until there is a viable public option offered in the exchanges. But that is something definitely worth fighting for.

    I agree that it is clear that very little good can come from our present political impasse. Republicans will fight and block everything they can. They will improve nothing. They will sabotage wherever possible. We're going to need to win electorally and then move fast.

    Frustratingly, we're not very good at that. Still, WE CAN IMPROVE!

  • j on March 22, 2013 1:01 PM:

    Do we have to go through congress to get a public option added, or is that up to the president?

  • lou on March 22, 2013 2:18 PM:

    I'd guess the real deal breaker may be the premiums offered by insurance companies competing in the exchanges. If they do not provide some evidence of real competition and discounted costs compared with what individuals are currently paying in the private health care market there is gonna be some big time cans of whoopass opened up.

  • RaflW on March 22, 2013 5:41 PM:

    Maybe I'm too optimistic, but I see the Minnesota exchange being set up on time and in a pretty positive manner, and wonder how long before folks look to places like Minnesota and say "Dammit, I want that. You obstructionist s.o.b.s are leaving me in a lurch."

    All that said, I have no illusions that the GOP will continue to do all it can to f*#k up ACA while they can.

    It's freakin immoral to deny care and coverage this way, and I hate that the Catholic Church has pitched in so whole-hog with the GOP on abortion/contraception/gays that while they generally oppose the GOP on ACA, the GOP knows many Catholics won't really hold them accountable for this utter failure to care for one's neighbor.

  • SoCal on March 22, 2013 6:35 PM:

    I agree with lou about the premiums. Here in CA we can get an estimate of what they will be, and they look to be high, especially for young adults (http://www.coveredca.com/resources/calculating-the-cost/).
    It would be interesting to know what premiums will be in other states.