Political Animal


April 29, 2013 10:43 AM The Optimist’s Case For Obamacare Implementation

By Ed Kilgore

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 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.


  • c u n d gulag on April 29, 2013 11:02 AM:

    "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..."

    Is that even possible?

    They hate Democrats.

    And they really HATE Obama!
    They hate him, to the point where, if he actually walked on water, they'd say, "Big deal. We know that 'Blah' guy's too lazy to swim. Not that any of them can, even if they wanted to."

  • Nancy Cadet on April 29, 2013 11:35 AM:

    Ed, I agree with Atrios when last week he observed that Americans will associate Obamacare with the US health care system, which is a mess, and all blame will be directed at Obamacare. Of course, Atrios said it much more succinctly.

  • Peter C on April 29, 2013 11:49 AM:

    Even if the implementation were flawless, the Republicans would scream that it was a fiasco. They own the media and have written the headlines years in advance.

  • mmm on April 29, 2013 11:59 AM:

    For starters, let's quit with the "Obamacare" and call it what it is... The Affordable Care Act. Thanks to the negative publicity, some people actually think it's a program, like Medicare, that you join. If the media would address very small portions at a time and explain it clearly to people, maybe a few attitudes would be changed. People won't embrace it if they don't understand it, but I know there will always be some who will never get on board, but let's at least try. Even short, 30 sec. cleverly produced public announcements would help. Just my opinion.

  • Rick B on April 29, 2013 12:26 PM:

    What both patient and the providers need desperately is predictability in the health care system. Until I got on Medicare the annual changes in what I was covered for were always a surprise, and usually an expensive one, that I had no way of changing.

    The Affordable Care Act goes a long way towards changing that for the better. The fact that providers will stop having to build in big markups in their prices to cover unexpected charity care they provide will lower predictable costs.

    Confusion in the changeover? It will be no worse than the confusion created by every annual change the employers make to lower their costs.

  • Pat on April 29, 2013 2:21 PM:

    One, you can try to change the term from Obamacare all you want, it ain't going to happen. It is its name for the public now. Two, unless there is something in it for the major donors to both our political parties there is not going to be incremental improvement. you can tell that by the fact that there has been more destruction to ACA then improvement in the years since it passage, as funding has been cut and some of the more progressive and patient friendly items have been eliminated due to the deficit. Three, the already inadequate regulatory system will be hampered or cut depending on what the Republicans and corporate Dems want (for the Swiss system to work even that meagerly the insurance industry is deeply regulated). Finally, as the government allows further and increased privatization of Medicaid and Medicare, those programs which actually are more sensible and provide more actual health care then our current insurance system will become a bottom line boom to the insurance companies who will provide less care for that boom - something that also dooms the "incremental improvement". IOW, Atrios' shitty system expands rather then contracts, and that is already happening. Not to mention that the very nature of the "Cadillac Tax" speeds the process of the people who have insurance getting less adequate coverage or even being thrown into the individual market by design.

    Oh, and as the financial assistance is either cut or held to current levels and becomes increasingly inadequate, it will become a further weight around people who will get insurance and no health care, or a big fine and no health care. But you keep believing in the shiny sparkly pony that this piece of crap will somewhat work and even be improved.

  • Barry Clark on April 29, 2013 3:28 PM:

    Atrios is wrong.

    Obamacare will be popular because people will no longer be dropped/recinded, pre-existing conditions will no longer be discriminated against, 26 and under on parent's insurance, etc etc.

    People are never going to want that taken away, and they will credit it to "Obamacare."

    In fact, in poll after poll, when people are told what's in "Obamacare", they like it. They don't like it in the abstratct.

    Just wait till they see more coverage and protections. Doesn't matter if it's not perfect. It will be better.

  • Zorro on April 29, 2013 3:33 PM:

    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.

    Given that Obamacare is based on a proposal that came from the Heritage Foundation as an alternative to the Clinton health reform plan, for conservatives to embrace it shouldn't be too difficult.

    But, as has been noted, the GOP will oppose Obamacare simply because it's, well, Obamacare. Were Obama to adopt the entire GOP platform from 2012, the GOP would be sure to oppose it.


  • MSB on April 29, 2013 4:03 PM:

    The road ahead is to flip Texas into the Blue column and chip away at the rest of the southwest. Try again in Hilary's second term when she wins in a landslide and the Dems pick up a bunch of senate seats they lost in 2014. Asuming -3 in the '14 cycle, Dems need to get +3 each in 2016, 2018 (e.g. Castro def. Cruz in TX, Flake in AZ, and maybe NV).

  • ELM on April 30, 2013 10:37 AM:

    What to do: Medicare buy-in for all.

    It's really that simple, which is why it wasn't done.

  • ELM on April 30, 2013 10:43 AM:

    To expand the point:

    What to do about Social Security's 'problem' coming in 20 damn years: Raise the cap.

    Everyone in DC knows this, and that SS adds nothing to the deficit.

    But watch the Kabuki hand-wringing and theatrics for the rubes, as they steal our retirement savings.

    It's a 10-second fix: raise the cap. I've heard Obama mention it--during campaigning, of course. Since then, nah, let's destroy SS in order to save it, because austerity.

  • Costa Rica's Call Center on April 30, 2013 1:00 PM:

    OBAMACARE enhances outsourcing. Enacted in July 2010, The U.S. healthcare reform (“ObamaCare” or the “Patient Protection and Affordable Care Act”) is intended to pressure large and small employers through force and taxation. The result will show companies deciding to send customer support, sales, lead generation and appointment setting jobs offshore or risk going out of business. U.S companies can take advantage of a dedicated bilingual employee who is 100% committed to their project. ESL nearshore employees in Costa Rica are just as or more effective than transitional in-house employees. In addition, giving the business the freedom to scale up their offshore staff strength without getting caught in the Obamacare challenge in 2014.