Reports of a ‘train wreck’ have been greatly exaggerated

Updated
 
Reports of a 'train wreck' have been greatly exaggerated
Reports of a 'train wreck' have been greatly exaggerated

At yesterday’s White House press conference, Chuck Todd asked President Obama about the challenges associated with implementing the Affordable Care Act. The president didn’t seem concerned, saying implementation is already well underway and the system is “working fine.”

That assessment is hardly universal. Senate Finance Committee Chairman Max Baucus (D-Mont.) caused a stir two weeks ago when he said at a hearing on the law, “I just see a huge train wreck coming down.” David Brooks last week devoted a whole column to his prediction of health care “chaos,” arguing, “It was always going to be difficult to implement Obamacare, but even fervent supporters of the law admit that things are going worse than expected.”

There have been all kinds of reports of worried officials fretting over hindrances, some substantive, some political.

And yet, there was Obama yesterday, seemingly undaunted. Is he overlooking the looming “train wreck”? Not really. Jonathan Cohn had a great item this week on the lay of the land, and while he notes the initial adjustment “may not be easy” once full implementation begins next year, some of the recent handwringing is a bit much.

The challenges are, of course, real. “Obamacare” has to overcome Republican sabotage efforts (at the state and federal levels), establish exchanges (the marketplaces for the uninsured), get the right people into them, and create the bureaucratic infrastructure to make all of this work. Spoiler alert: there will be bumps on this road.

Then there are the benefits.

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.

Meanwhile, the 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.

I tend to think the law will be implemented with fewer crises than its critics predict, though I worry about policymakers’ capacity to make subtle tweaks as needed.

Kevin Drum had a good piece on this the other day.

No big law is ever perfect. But what normally happens is that it gets tweaked over time. Sometimes this is done via agency rules, other times via minor amendments in Congress. It’s routine. But Obamacare has become such a political bomb that it’s not clear that Congress will be willing to fix the minor problems that crop up over time. There’s simply too big a contingent of Republicans who are eager to see Obamacare fail and are actively delighted whenever a problem crops up. This has the potential to be a problem that no other big law has ever had to face.

We’ll see how this works out. Maybe after 2014 things will cool down a bit and normal horse trading will start up again. But I’m not so sure anymore. After all, I figured that might happen after the November election, and when John Boehner acknowledged that “Obamacare is the law of the land,” it seemed like a good sign even with all the hedging he put around it.

But nothing has changed.

No, not even a little. On the contrary, the only meaningful Republican health care plan is to vote, over and over again, to repeal health care reform, even though it can’t pass, and refuse requests for constructive policy proposals of their own. So, in the event Congress is needed to improve minor elements of the law, it’s likely those fixes simply won’t happen – because GOP lawmakers will prioritize dysfunction. It’s preferable from their perspective to say, “See! Obamacare isn’t working exactly as advertised!” than to govern.

Still, despite this, I’m cautiously optimistic about the big picture and think the reports of a “train wreck” have been greatly exaggerated. The consumer protections are in place, the regulatory rules are being written, the exchanges are in motion, and by the time the 2014 midterms roll around, I suspect the derided law will be a whole lot more popular than it is now.

Affordable Care Act and Obamacare

Reports of a 'train wreck' have been greatly exaggerated

Updated