Iowa may be the latest Republican controlled state to expand its Medicaid program. The federal government is poised to approve a waiver that will allow Iowa to use federal funds to purchase private insurance for individuals eligible for the expansion while charging some a premium for their coverage. I’m not thrilled with the idea of requiring people who live near the poverty line to pay a premium for Medicaid. But if this is the kind shell game conservatives need to play to convince themselves that they’re remaining true to their skewed free-market principles, then fine. It’s a better option than completely denying health coverage to people for no other reason than geography. And perhaps the feds’ flexibility on the mechanics of the expansion will encourage other red states to follow suit and do the right thing for their citizens.
The Times ran a great piece over the weekend that pulled back the curtain on the unfolding disaster that was the healthcare.gov website. It details the bureaucratic bungling and poor oversight that led to the disastrous rollout of the site. The website’s performance seems to have improved as a result of the administration’s intensive repair effort, but problems could still crop up on the backend components that are responsible for transmitting enrolling information to insurers and for processing subsidy payments to insurers.
As President Obama has already admitted, he and his appointees badly mishandled this crucial task. Presidents shouldn’t be micromanagers, but Obama’s hands-off approach and the general insularity of this administration only served to undermine his credibility when it counted most. The politics of this clusterfuck are transitory; what really matters is whether the underlying policy succeeds. I still think success is likely, but I worry about our collective willingness to take bold action on other issues like climate change and income inequality. Government must constantly demonstrate its effectiveness and relevance to people’s lives. Unforced errors like this only give fodder to those who would be too happy to live under a government that stands an army, paves the roads, and not much else.
The federal government released its first ACA enrollment figures and, as expected, they reflect the troubled rollout of the healthcare.gov website. Less than 27,000 people have enrolled in a private health plan through the federal exchange. Compare that with approximately 35,000 people who enrolled in a health plan through the California exchange. In fact, California alone accounts for a third of the total enrollment in private plans (about 106,000). On a more positive note, nearly 400,000 people have enrolled in Medicaid, supporting my theory that the Medicaid expansion will prove much more critical to expanding access to health care than most people realize.
The enrollment numbers are certainly low, but I’m not going to worry unless the trend continues for another couple months. And the best way to increase enrollment is to fix the website.
MNsure, Minnesota’s insurance exchange, released its October enrollment numbers today. Nearly 11,000 people have enrolled in coverage; over 9,000 have enrolled in Medical Assistance or MinnesotaCare. This is consistent with enrollment data from other states indicating Medicaid enrollment that far exceeds enrollment in private health plans. It’s too early to draw conclusions from one month of enrollment data, but it will be interesting to see whether the trend persists. It could be that low-income people are more motivated to enroll in coverage and that these numbers will even out as the enrollment deadline approaches. It may also indicate that the Medicaid expansion is more critical than we first realized. The data also raises questions about increasing health care disparities between states. A low-income family in Minnesota will have much better access to health care than a low-income family in South Dakota.
Having failed in their efforts to repeal the Affordable Care Act, conservatives are now trying to blame Obama for the health plan cancellation notices that are now going out to customers. They point out that Obama previously stated that people who liked their current plans could keep them and that those statements must have been either deceitful or ignorant.
First, Obama and Democrats have never been great at explaining the details of the law. Politicians generally aren’t wonks and they don’t like making wonkish qualified statements like “Most people will be able to keep their current plans.” Second, the cancellation of these plans is a feature of the law, not a bug. These plans didn’t comply with the ACA because they didn’t offer certain essential services or they had excessive cost-sharing requirements. The ACA-compliant plans will offer richer benefits and stronger cost-sharing protections. Yes, some people may end up paying higher premiums than they do now, but this seems like an acceptable trade-off to me. It’s not as if most people on the individual market were terribly happy with their current individual plans.
If people want to argue that we should be allowed to pay for crappy coverage, that’s fine. It’s just not a terribly compelling argument.
Ezra Klein calls the launch of Obamacare a failure. It’s difficult to dispute that assessment, at least in regards to the federal insurance exchange. The Times ran a great article detailing the various missteps behind the failed launch. It’s a discouraging but familiar story involving miscommunication, lack of resources and accountability, and political hedging. Things are going somewhat better in the states operating their own exchanges where they can respond more nimbly to technical issues.
The feds need to fix these problems and hold the appropriate people accountable. But it’s worth pointing out that the fierce opposition to the ACA likely contributed to its rocky implementation. The administration didn’t plan on creating an exchange for 36 states, but the political circumstances gave them no choice. It doesn’t excuse the massive implementation failures, but it does provide context.
There’s still time to fix these issues. The administration can’t afford to dither, though. People already have a shaky trust in the government and screw-ups like this only weaken that trust further.
Most people don’t have the time or patience to understand the political dynamics that led to today’s government shutdown. But let’s be clear about the root cause: the federal government is closed because Republicans do not want people to have access to affordable health insurance. It’s that simple. Republicans love to frame their zealotry as a defense of freedom; namely, the freedom to be bankrupted by a heart attack or car accident. It is this distorted, nihilistic, utterly fucked-up notion of “freedom” that has transformed the GOP into a party that is incapable of governing responsibly.
Republicans promised to unveil an alternative to the Affordable Care Act back in 2011. Two years later, they have still offered nothing because Republicans are fundamentally uninterested in health care reform. For them, the old, dysfunctional, highly uncompetitive insurance regime worked just fine. And if you were excluded from that system, well, you just weren’t deserving in the first place.
This shutdown will eventually end (hopefully, without a cataclysmic debt default) and the exchanges will continue to enroll people in coverage. Unfortunately, we’ll have to endure an extended conservative tantrum and the pointless idling of a million workers first.
Here are a few things to keep in mind in advance of tomorrow’s roll-out of MNsure:
- No Rush–Like any tech roll-out, MNsure will probably have its share of bugs that will cause problems in the opening days. Since coverage doesn’t begin until January, there’s plenty of time to sign up. Don’t panic if the website is occasionally unavailable.
- Insured through Your Employer?–You may still be able to purchase coverage through MNsure if the insurance offered by your employer is not considered affordable. Generally, coverage is not affordable if it costs you more than 9.5% of your income.
- Shutdown? What Shutdown?–Even if the federal government shuts down tonight, MNsure (and the federal exchange) will be open for business tomorrow.
- Have More Questions?–Sarah Kliff has you covered.
While Ted Cruz and his fellow conservatives mount yet another doomed effort to derail Obamacare, Canadians are pointing at us and snickering. Even the super-wealthy Canadians can’t understand why a relatively modest set of reforms provokes such conniptions among American Tea Party types. Compared to the single-payer systems found in Canada and much of Europe, Obamacare preserves the status quo to an almost embarrassing degree.
The Affordable Care Act has plenty of flaws and shortcomings that should be addressed. It’s too bad that Republicans can’t engage in a reasonable discussion about how to improve the law, but the Tea Party has rendered the opposition incapable of discussing policy. Their willingness to shut down the government and risk a debt default in order to deny people health insurance isn’t just conservatism run amok. It’s a deeply reactionary response to a rapidly changing world, mixed in with some not-so-subtle racism for good measure. I’m not sure how you persuade people with that mindset to accept reality. And that’s why I’m more than a bit worried about what the next few weeks will bring.
Even after a Supreme Court ruling and a presidential election, Republicans remain fixated on dismantling Obamacare. Their latest strategy is to defund Obamacare by holding the federal budget or the debt ceiling hostage. Jonathan Chait’s recent piece on the ongoing plot to destroy Obamacare provides keen insight into the fears driving this last, desperate rearguard action by conservatives. Despite making nonstop proclamations that Obamacare is already a failure, conservatives rightly worry that Obamacare will successfully provide affordable health coverage to millions at affordable prices. It could redefine the role of government in a key component of both the economy and daily life, a prospect that most conservatives simply can’t abide.
These last-minute hijinks will come to nothing. The President and Congressional Democrats will never agree to anything that delays or defunds the most significant social legislation of the past forty years. It may take a government shutdown or a flirtation with financial ruin to bring Republican leaders to the realization that their Tea Party colleagues must be abandoned in the wilderness for their party to survive.