Thursday, November 28, 2013


The Sun Will Come Out, Tommorrow

Although not known as that much of a Pollyanna, ├╝ber-leftist Josh Marshall, Princeton grad with a PhD in American history from Brown, comes out swinging at the doom and gloom many Democrats are feeling as the Orwellian titled Affordable Care Act ("ACA") under-performs even the most pessimistic of Republican predictions. He's a cross between Annie and Kevin Bacon at the end of Animal House, but not as convincing. Here is the piece, titled A Realist's (snort of derision) Take on Obamacare; let's get to it.

Supporters of Obamacare were tepid, he writes,

Then they were hit with the wholly unexpected surprise of a botched website roll out that set the whole public opinion war back on its heels and then a wave of cancellations that were reported in a misleading way (and only affected a tiny portion of the population) but nevertheless further soured public opinion.
Perhaps the failure of the Web site and exchanges wasn't completely unexpected. Even a handful of policy cancellations made President Obama and his Myrmidon Democrats liars but it's over 5 million who have lost coverage. It's difficult to credibly dismiss so many as a tiny portion. It is also very dangerous to do so because the wave of cancellations credibly predicted for the employer-provided plans will be tens of millions. How to minimize the damage then, Josh?

But for all that, here's why I think the generally cataclysmic press is overblown and why the law will be a success.

The program is actually doing pretty well in states that have functioning websites. 

No, not really doing well, much less pretty well on the state sites. Oregon, Colorado, California are all pretty much horror stories for ACA supporters and I could go on and on.

I base this relative optimism on four assumptions.

The first is legislative: regardless of firestorms about this or that, this law will not undergo substantive changes before January 2017. In practice, President Obama has complete control over this part of the equation. Even with a Republican blowout in 2014 (which I think highly unlikely) and lots of Democrats turned against the law, it's virtually impossible that a presidential veto could be overridden. "Substantive changes" can mean lots of things but I mean new legislation aimed at repeal or gutting the law. Nothing will happen on the legislative front that Obama doesn't approve of. This is a cardinal fact.

I agree that even if it goes as it looks it might well in 2014, Obama will be able to block repeal with a veto that will probably not be overcome. But what Josh sees as a feature, clear sighted others see as a bug. That the President will not allow substantial change while he is in office means that he will give his supporters enough rope to hang themselves. A reasonable president, seeing things go so south that it could permanently hurt the Progressive brand, might pull the plug. Not Obama. The burning airplane of Obamacare will be free to plunge all the way to to the deck.

Second and under-appreciated: the major national insurance carriers have heavily bought into the "Obamacare"/exchange model and have spent almost three years retooling their business models to prepare for it. It's too much to say there's no going back. But the carriers themselves are about as close to being locked in as you can get. Any decision to reverse course and go back to the old system is fraught with real danger. So the carriers themselves have huge incentives to make the system work.
Probably true, but it is not clear what the formerly evil major national insurance carriers could do to make the ACA more popular with the people who actually have been affected by it.

Third: By early next year you will have millions of new people enrolled in Medicaid, large numbers of people who have health care covered who couldn't get it at any reasonable price before who now have coverage and you will have large numbers of people who have care that is better or cheaper and often both than it was before.

Medicaid is not actually the Nirvana Josh makes it out to be. In fact, it is the blighted ghetto of medicine, with the least pay enticing only the worst doctors to jump in. It offers the kind of care Helen Hunt was getting for her son in As Good as it Gets. I'm not sure banishing more people to barely standard care is something to be happy about. As to the "better and cheaper" meme, I've yet to hear of large numbers of new enrollees praising their new better/cheaper plan. In fact, all I've heard is the opposite. With a lap dog media completely pulling for the President and the success of his single 'achievement,' the lack of happy endings getting press coverage must be a little disconcerting for the left. Josh is able to shrug it off.

Yes, you will also have people who had barebones policies who will have to buy into more expensive policies with fuller coverage. On balance, those people will tend to be more politically connected and visible, person for person, than the people on Medicaid for instance.

But we were told the new policies would be cheaper, by about $200/mo. I guess the President lied about that. And yes, when a lefty yuppie whines about losing a plan he or she liked and about having to buy a worse plan  for much more money (albeit with both mammograms and prostate screening covered by regulation, so they have that going for them, which is nice), we on the right take notice (and no small amount of glee).

But all evidence shows the first three groups [Medicaid, first time, cheaper/better enrollees] will vastly outnumber the last group [paying more]. I do not think anyone will be able to claw that back. It's one thing to have millions of uninsured or people boxed out because of pre-existing conditions. But once they have affordable coverage, I don't think you're going to be able to take it back.
The optimism here depends on: 1) The formerly uninsured enrolling (no sign of that yet); 2) The tiny portion (better measured in thousands) of locked out by pre-existing conditions gaining access (not likely to cause a huge wave of popularity there); and, 3) Anyone actually getting cheaper plans (even the CBO says the ACA bends the cost curve of coverage up). I say wan hope that any of these will happen to enough people to overcome the millions losing health plans they like and can afford.

Now Josh gets real with us. It all could go wrong, he admits,

But I think there's very good evidence to assume this based on the experience in Massachusetts, the opinions on policy experts I respect and actually a lot of data we're already seeing even in this very bumpy roll out.

Mass. has the most doctors and the longest waiting times for getting in to see one in the nation. How could that be possible if RomneyCare is something to emulate? And isn't it the policy experts with opinions who drafted this monstrosity in the first place? Is there any hopeful data out there? Who's been keeping it secret then?

Obviously, if the policy really is a failure, if it leads to risk pool death spirals, market failure, skyrocketing rates for everyone, then eventually reasons one through three will eventually be beaten down by that reality. But I see no real reason to think those will happen in part because I think it's fundamentally a workable policy and especially because of the political and stakeholder buttressing of reasons one through three.
OK let's see if I can point out why the ACA just might not be fundamentally a workable policy. By taking away the threat of not covering pre-existing conditions, you undercut several of the reasons why healthy people, who don't need health insurance, choose to make the sacrifice to obtain it (and thus prop up the system for those who are unfortunately not healthy and do need it). There is no reason not to wait now, especially if you're young and healthy, to get health insurance only after you need it. The penalties taxes for not having it are nowhere near severe enough to cause someone to sacrifice to cover only the highly unlikely, debilitation accident. If the people who don't really need it, don't sign on and prop up the market then there will be risk pool death spirals, market failure, skyrocketing rates for everyone and the policy will have been a complete and utter failure, perhaps the worst failure of legislation since Prohibition. But clearly Josh knows the risks, he merely is in denial about the lack of ACA's mechanisms to prevent just that. Then he writes some real drivel which I'll skip over. Big finish.

We didn't pass Health Care Reform for it to reap electoral gains for Democrats (though I think it still will) or to have it be popular, per se (though I suspect it will be). The aim was to get people covered, make the health care provision system more efficient and reduce the scale of human suffering, especially the spectrum of suffering tied to your wealth and your luck.

By that standard, I think it will be a success and I think there will be no going back. And that's the only standard that matters.
If the law is not popular, wouldn't that necessarily mean it's not doing the greatest good for the greatest number of people? Just asking. And I fail to see how the ACA is even beginning to fill the role of getting more people covered when the number of people with cancelled policies who cannot buy a replacement policy at a price they can afford outnumber the new enrollees by several orders of magnitude. And that's just the first, tiny portion, wave. What is in the ACA, with its added complexity and bloated bureaucracy to enforce it, which makes it more efficient? How is it reducing human suffering if it isn't getting more people covered? The telling part of the whole piece is the bit about 'spectrum of suffering tied to wealth and luck.'  What in God's name is he talking about? Poor people feel more pain of an injury than rich people feel for the same injury? Rich people suffer less anguish from hearing an out-of-the-blue prognosis of pain until imminent death than a poor person hearing the same prognosis would suffer? If it is unlucky to suffer any any injury or illness, what, particularly, in the ACA does a thing to mitigate that?

This seems the most important part to Josh and his ilk. Equality of suffering. Suffering divorced from wealth or luck. This is, of course, nonsense and the very last thing to say in praise, such as we can, of the ACA.

Shorter version: We're stuck with the ACA and it will not suck so bad it fully fails and we'll get used to the sub-failure suck and the Democrats get to chalk up a win. Hooray!

I'd be optimistic about that probable course of events too.

The sun will come out tomorrow, so ya' gotta to hang on 'til tomorrow!

If you can.


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