Among people along all three axes.
1. The progressives are much less forgiving of the Obama Administration’s management failures than are the rest of us. Some of us saw the problem as baked into the law. It was pointed out that the law mentions the word “web site” over 130 times, which is an indication of how complex the requirements could be. I made my point that Amazon and Kayak emerged out of a tournament involving thousands of companies. I said that if Obamacare had been a private-sector start-up, its odds of success would have been less than one in a thousand. Others pointed out that in the private sector you usually start with a small, minimally-functional prototype, not with a full-blown, full-featured system. Still others pointed out that the features of Obamacare are so tightly interconnected that it required perfect execution, which was extremely unlikely.
The progressives (especially those over age 40) wanted instead to emphasize the fundamental management flaws, such as not having a strong executive in charge of the project. They insist that Obamacare could have worked. Clearly, to suggest otherwise was to cast some doubts about the progressive approach.
2. The suggestion that some of us had of creating a “data extract” for the web site, so that it did not have to access other databases in real time, could not have been implemented. There is a law against the IRS giving out copies of its data.
3. The story was told that when Medicare Part D debuted out (in 2003, I believe), the launch was delayed three weeks because the system was not considered ready. Someone said that the Bush Administration put out the story that they did not want to launch the site on the Jewish Holiday of Yom Kippur. Of course, that is only a one-day holiday. Someone (not Jewish) joked that “But then you have sukkot” (a week-long holiday that comes a week after Yom Kippur). The best hope for Democrats is that the web site works well quickly
4. Nobody of any persuasion was buying David Cutler’s line that the slowdown in health care spending since 2008 reflects Obamacare.
5. Some of the state exchanges may be working better because states have been given an exemption from verifying eligibility for subsidies (at least, that is what I heard people say, but I may be wrong)
6. One journalist insisted that when President Obama announced his recent “fix” that would allow insurers to renew old plans, everyone knew that this could not possibly be implemented. The journalist said that the whole point was to keep the Senate from voting on a proposal to implement the fix. I guess the choice is between believing that Obama was an idiot (for thinking that state insurance commissioners and insurance companies could pull off a renewal so quickly) or a liar, and this journalist, who tends to be sympathetic to the President, implied that Obama (once again) was being cynically deceptive.
7. It was pointed out that non-libertarian Republicans should be sad about the failure of healthcare.gov, because many Republican health-care reform proposals have involved some sort of health exchanges.
8. People said that it is hard to make big policy moves in today’s environment. Trying Obamacare was like trying to privatize Social Security. President Bush wisely backed off of the latter (although he was not trying to privatize the entire program), and perhaps the Democrats would have been wise to back off the former.
9. President Obama’s reputation with young people as being “cool” has taken a tremendous hit. This could have long-term implications for how young people look at politics. My thought (which I kept to myself) is that at the moment President Obama seems to be adapting Atlas Shrugged for the 21st century.
10. The scenario for Obamacare’s death is that the insurance companies “defect” by leaving the exchanges or raising rates to unacceptable levels. As Obama’s personal political strength weakens, the “defect” scenario becomes more plausible.
The “big policy moves” line of thought seems important to me going forward. Obamacare was pushed in over substantial opposition. Much of Congress opposed it, many states opposed it, and of course much of the general public opposes it.
For a change as big as the individual mandate, it should seemingly take more than 50% support and a president that, himself, has less than 50% of the public support. It should be more like the constitutional process.
Part of the problem is that the next administration might just turn it all upside down again; this is less likely if you wait for changes supported by a super-majority. Part of the problem is that you can’t implement something properly if half the country is trying to tear it down. Part of the problem is just democracy. If a double-digit percentage of the country really hates an idea, then why do we have to get sucked into it?
Get a grip. “They insist that Obamacare could have worked.” It’s not even Thanksgiving yet.
Much depends on what is meant by “worked.”
As a system designed to provide enforced cost-spreading (cost-sharing if one is sensitive) through the instruments of prescribed private (civil) contracts, this legislation is pre-ordained to encounter exposure to unwillingness and/or inability of participants to enter into the conditions (and necessary concept) of contract.
As constructed, the present (and foreseeable) available coercions will not provide sufficient force to motivate participation from one side. Implicit in the provisions for subsidies is the recognition that the other participants needed to convert transfers and spreading of *risks* to transfers and spreading of *costs* are not unlimited in financial capacities – forcing them to withdraw.
While the truism: “All costs must be covered” stands, the modes of required spreading or sharing of costs are limited. This legislation does not provide one of them.
” President Obama’s reputation with young people as being ‘cool’ has taken a tremendous hit.
” This could have long-term implications for how young people look at politics.”
Perhaps “how” the young of **today** will do so; but, they too will “mature.”
The young of the “tomorrows” will have to experience their own charismatics .
Somehow I don’t think that’s what the progressives Arnold was talking to had in mind when talking about the website and the “strong executive” problem.
Well, that should have been in response to the above thread comment at 1:47.
“10. The scenario for Obamacare’s death is that the insurance companies “defect” by leaving the exchanges or raising rates to unacceptable levels. As Obama’s personal political strength weakens, the “defect” scenario becomes more plausible.”
The exchanges turn into de-facto high-risk pools as people on the individual market who don’t qualify for subsidies get better deals buying policies off the exchanges. These may be from insurance companies who don’t participate in the exchanges (and therefore don’t need to include sick, expensive exchange buyers in their risk pools). Some insurance companies will specialize in subsidized exchange plans. Others will sell to individuals only off the exchanges, but few companies will do both. At the same time, most employers (even relatively small ones) switch to self-insurance plans to sidestep costly Obamacare mandates.
And what are we left with? A program that provides subsidized insurance for low-income and expensive-to-insure people. This latter group will also include retirees who are too young for Medicare (and who may have high levels of wealth but low incomes). In this scenario, Obamacare doesn’t have to die, exactly, it could remain as a costly, high-risk program for a small percentage of Americans.
The Affordable Care Act is a close approximation to the health insurance measure enacted in Massachusetts during Mitt Romney’s administration, which in turn was based on the successful and highly popular health care systems in Germany, the Netherlands, and Switzerland. Unless somebody convinces me that Americans as a whole are fundamentally different from the residents of Massachusetts, Germany, et al, I’ll continue to believe that the Affordable Care Act will succeed in its main goal, providing medical insurance to those unable to obtain it. I’ll add that conservatives and libertarians would benefit by setting aside preconceived notions and actually paying attention to the real world.
It does not seem you are aware of how healthcare in The Netherlands actually works. It’s more like a public/private partnership. Hospitals are government run, but not free. You have to pay for them.
Below a certain income level, people get state insurance, i.e. “free” healthcare. It’s strictly rationed, and you get to the back of the queue of everything (it’s slightly more complex but at helicopter level this is how it works for electives, not for emergency obviously). If they possibly can people will try to get private insurance, and then you have uninsured, some paying out of pocket, some without insurance for religous reasons.
Healthcare in The Netherlands is basically (Medicaid + Medicare + rationing) + private insurance.
There are few private providers, so even with private insureres you have to go through the state system which rations access obviously.
There are not really government mandates at a level you have in the US (there’s some, i.e. you’re forced to pay sick leave, pregnancy leave, that kind of thing).
“its main goal, providing medical insurance to those unable to obtain it.”
Part of the problem is that it can’t decide what it’s main goal is. Most often, I’m told that the most important effect is supposed to be to rein in the soaring healthcare costs, given that America spends more than other countries while (putatively) achieving worse results. Which is it?
“Unless somebody convinces me that Americans as a whole are fundamentally different from..”
It’s not necessary for the people to differ. An alternative explanation could be that the result is path-dependent: the other implementers took a different course through history, which allowed them to arrive successfully. It could also be that the limitations that we place on our federal government are such that details emerge that from the design possibilities that we’re limited to, resulting in failure. I don’t know which, if any, of these explanation obtain, but they’re plausible.
Stan, for something to work it has to survive both a short term implementation hurdle and the long term sustainability hurdle. I have little doubt that the PPACA can survive/muddle/thrive through the long term, but the short term implementation is a much bigger hurdle. Germany and Massachusetts implementations were less ambitious in terms of size and diversity of insurance marketplaces. But, an airplane modelled on a perfectly workable balsa wood model may still be unable to fly.
In shorter terms: not all things scale to the size of the U.S. This may be one.
A fair comparison (not entirely fair, but for these purposes it would serve) would be if you imposed the German healthcare system to all of the EU, how difficult would that implementation be? How much resistance would it face? How much support would it gain? How well would the separate markets operate (especially since each country would have its own market)? What concessions would various interest groups impose? Who would be the winners, and who would be the losers, and how extreme would each be in support of their position?
You might very well destroy the European project by such an effort.
“Stan, for something to work it has to survive both a short term implementation hurdle and the long term sustainability hurdle.”
I actually think the long term sustainability hurdle is the much bigger issue. The question is to what extent the short term implementation undermines long term sustainability.
I don’t know how much “fundamentally different” you require, but, as an American, with Midwestern and Southern background, currently serving as a displaced person in the Commonwealth of Massachusetts, I observe that the current residents of Massachusetts differ fundamentally from most other Americans I have encountered over almost 90 years of past existence and experiences.
That experience also includes exposure to, and working with, peoples of the Netherlands, Germany and Switzerland (from which my family descends), and by that experience, through the year 2000, there was ample evidence of fundamental differences.
Individuality and its requirements have always differed greatly in America from those in Europe. The intensity of its importance appears to the lessened, certainly in the political sense, in Massachusetts, urban New York and certain other urban centers of this country. There has been a gross misreading of the importance of that individuality in the legislative override of public opposition to this legislation. The effects will be limbic.
What makes you think that a close approximation of an existing working system must therefore be a working system itself? Small changes can cause an entire system to collapse.
There are very big and important differences between Obamacare and Romney care – and the other systems you mention. I do think there is a basic difference in the US – the individual mandate really grates on us Libertarians. My impression is that it is less troubling to most Europeans.
But the biggest problem is that Obamacare is much “bigger” – it covers a lot of stuff.
This expansiveness is intentional – but will also prove to be a fatal flaw. The scope of the plans needs to be very broad to raise as much revenue as possible. This provides the funds to support the transfers to the poor and unhealthy. Had they settled for less – premiums would be lower – but so would the funds available for subsidies.
I remain dismayed by how many people think that we need to have providing health insurance as our goal – not providing the best possible health care.
The ‘fix’ to allow the renewal of old plans was simply to divert attention to the failure that is American health care. Obamacare has problems but most of them it inherits from trying to change the existing dysfunctional system as little as possible. There is no alternative to making it work, but it will work well where supported and badly where unsupported.
“The Affordable Care Act is a close approximation to the health insurance measure enacted in Massachusetts during Mitt Romney’s administration”
It’s not a close approximation insofar as the latter was a state level program. In the normal course of events, as per the tournament of thousands, alternative ideas would have competed via implementation in the 50 (or subset thereof) states. The state or states that worked out the bugs could have served as models, and the natural trial and error/ organic/bottom-up process would have delivered a tolerably good menu of choices for the other states.
The Obamacare top down one size fits all DC centric approach is the exact opposite of Romney’s approach.
The MA legislature changed Romney’s healthcare proposal. Romney didn’t like it, but went along anyway. I blame him for that. I suppose he didn’t want the label of being against his health plan before he was for it.
http://mittromneycentral.com/resources/romneycare/
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1 – The item Romney most vigorously opposed was the “Employer Mandate” which required that all businesses with 11 or more employees provide health insurance to those employees. In his view, an employer mandate was an unnecessary burden on businesses in the state.
Romney believed that the employer mandate would harm low-profit-margin businesses (such as new or struggling businesses) and that it could reduce wages, or distort employment patterns.
2 – Minimum Coverage Options – Romney wanted a “higher deductible” option of health insurance that would pass the state’s “minimum-coverage” guidelines. Romney wanted to give the citizens of MA the option to buy a bare-bones policy that covered only hospitalization and catastrophic illness.
That idea was rejected by the legislature. Instead the legislature mandated benefit-rich insurance plans (also called “gold-plated” insurance plans). “We wanted no mandated benefits,” Romney said in a recent interview. Imagine the additional cost imposed on the state and the individual by mandating these benefit-rich insurance plans.
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EasyOpinions
“My thought (which I kept to myself) is that at the moment President Obama seems to be adapting Atlas Shrugged for the 21st century.”
I would be really interested in hearing you elaborate further on this point.
Obama seems to be adapting Atlas Shrugged for the 21st century.”
The people will not act, the insurers will withdraw and not act and the legislative branch will not act.
During the health care debate I read that if the Affordable Care Act passed employers would cut hours to avoid the employer mandate, young people wouldn’t sign up for health insurance, and, paradoxically, the law would cause a massive shortage of health care providers. I read the same stuff about the Massachusetts health plan, often written by the same people. If any of the dreadful things they predicted had come to pass I think I would have heard about it. They didn’t. So, to repeat, I think that when the dust settles the ACA will be as popular nationally as its Massachusetts counterpart is locally. I also think conservatives ought to consider looking at the real world rather repeating rote phrases cribbed from SS Friedman and Rand.
What I wrote about Massachusetts was that it would cost much more than forecast. That turns out to be true. You can make a program popular with recipients by throwing money at them. The trick is to try to cover your tracks with taxpayers.
So why doesn’t Massachusetts repeal the program?
repeal would be embarrassing. They have looked into price controls for health care providers, but I am not sure where that stands.
It’s hard to repeal, or even just adjust, a troubled government program?
Gee, that’s never happened before.
Romney/Obama Care
Democrat Timothy Cahill was Massachusetts’ State Treasurer.
He said on 3/16/10 (Cato @ Liberty):
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[edited] Implementing the MA health insurance reform nationwide will threaten to wipe out the American economy within four years.
Our experiment has nearly bankrupted Massachusetts. Only federal aid is sustaining our law. We’re being propped up so that Obama can drive a similar plan through Congress.
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“if Obamacare had been a private-sector start-up, its odds of success would have been less than one in a thousand.”
Since start-ups are often failures because they built the ‘wrong’ thing, not because they built something that didn’t work, this isn’t a great comparison.
This is kind of a nit, because I think you (Arnold) know this, and maybe said this, but just gave us a quick summary in your post.
Obamacare was not necessarily the right thing to build, either.
One of the most concerning things I’ve heard is the renewed push for single payer:
http://theanonymouscommentator.blogspot.com/2013/11/why-i-dont-like-single-payer.html