We’re six weeks into the implementation of one of the key provisions of the Affordable Care Act, the rollout of the healthcare marketplaces. It’s been a tough month, dominated by failures of rather astonishing proportions. But sooner or later, Healthcare.gov will work, and Republican governors will grasp that bipartisan cooperation with the Obama administration is in their best interest.
First, let’s acknowledge the failures. The most obvious occurred within the Obama administration itself, whose Department of Health and Human Services botched the launch of the online marketplace. For those of us who worked so hard over many years to secure passage of healthcare reform, this was humiliating. We argued for years that the individual and small-group insurance market required greater transparency, along with closer regulation by competent, activist federal government. The ACA was a strong step in that direction, but no one expected completely smooth sailing in the implementation of a vastly complex new law. Plus, the Obama administration faced implacable opposition from Republicans at both the state and the federal level. The HHS bureaucracy labored under incredible pressure because of congressional efforts to defund ACA. The Supreme Court damaged and delayed ACA’s implementation, too—first through a ponderous legal process, then through its surprising and misguided decision that effectively allowed states to refuse ACA’s Medicaid expansion. Almost everyone expected the rollout to include some embarrassing glitches. But few people expected the deep bureaucratic failure that actually occurred.
ACA supporters draw different lessons from this experience. Technocratic centrists seek organizational strategies to make government IT management and procurement better emulate its innovative counterparts in the private sector. Those further left note that universal social insurance is more straightforward to explain and to actually implement. These critiques do not conflict. Both have considerable validity. Both deserve greater attention in the design of future social policies.
Last month’s performance failure hurts on a personal level, too. Many of us who fought for ACA are trying to help friends, patients, clients and loved ones sign up for coverage. We know many people who desperately need help, yet who remain confused or suspicious about whether they would get help under the new law. We finally had our chance to demonstrate that help was finally coming. But instead of being a moment of pride, October 1 was a moment of great confusion, embarrassment and disappointment.
I remain proud of ACA, proud of President Obama for securing its passage. The past month hasn’t changed that. My friends and colleagues in that effort feel the same. Yet I sense a new weariness and uncertainty. Unlike other low points of the Obama presidency such as his loss of the first 2012 debate, the rollout of Healthcare.gov represented a substantive governance failure rather than a partisan setback. This really hurt.
Then there was the line: “If you have insurance, you can keep it,” Obama’s promise that existing insurance policies wouldn’t change. Policy wonks always understood that this was roughly correct, but oversimplified. We failed to prepare the public for a more complicated reality, in which insurers would drop low-cost—often but not always—junk plans. Yes, most consumers are getting better plans. But some people are paying more. The president’s promise has come back to haunt him. He was right to apologize.