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Will ACA implementation succeed or fail?

Posted by John McDonough  July 19, 2013 01:47 PM

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Must read article in the Washington Post this week by Ezra Klein and Sarah Kliff on the implementation of the Affordable Care Act/Obamacare: Obama's last campaign: Inside the White House plan to sell Obamacare. The ACA is the most complex domestic policy implementation in U.S. history, and chances for screw-ups are significant, especially when the opposition is doing everything in its power to encourage screw-ups, and then to blame the Administration for them.

Here are some of my favorite excerpts:

"When I hear the conventional wisdom about Obamacare," said Jeanne Lambrew, deputy assistant to the president for health policy, "this is the difference between the Karl Roves who put their fingers to the wind and the Nate Silvers of the world who looked at the numbers."

Jeanne Lambrew has been working on U.S. and state health reform for decades, and has been indispensable since before Obama took office. She is the most important person on the ACA you've never heard of. Karl Rove, of course, was known as George W. Bush's brain, and the mastermind of the Republican strategy to elect Mitt Romney and a Republican-controlled Senate in 2012. Nate Silver is the polling mastermind at the New York Times who predicted 49-50 states' electoral choices in the 2008 and 2012 presidential elections.

"In 2011, there was this 'we're going to save the world' mentality," said Rebecca Pearce, executive director of the Maryland Health Benefit Exchange. "In 2013, it focuses more on 'How do we deliver on the requirements of the law?'"

Maryland is one of the states working the hardest to implement the ACA successfully. When Republican governors claim that the ACA can't work, it will be the states like Maryland that will tell the real story. If the ACA can't work in Maryland, California, Minnesota, or Connecticut, it will be hard to work nearly everywhere. If it can work, the question will become -- what's the matter with you other folks?

"How do you explain this in a way that seems fair and reasonable, that the higher-income people get help but you don't?" said Mike Perry, a founding partner at polling firm PerryUndem Research. "Advocates on the ground are really struggling with that group. They want to have a positive message but don't know what to say."

This is the reality of the of the June 2012 U.S. Supreme Court ruling that the Medicaid expansions in the ACA must be optional for states, rather than mandatory, as was written in the ACA. I hope people get mad when they realize this deep injustice, and I hope they hold accountable the Republican office-holders in those states -- because it is ONLY Republican governors and legislatures who are blocking the Medicaid expansion. I hope they get furious.

In fact, the vast majority of the young adults expected to be in the marketplaces are expected to qualify for subsidies. Linda Blumberg, a health-policy analyst at the nonpartisan Urban Institute, has done extensive work modeling who is likely to sign up for insurance on the exchanges. She estimates that 96 percent of 21- to 27-year-olds will get some income subsidies.

This is a key point that gets missed in all the predictions that young people will face huge health insurance premium increases. The vast bulk of them will be eligible for insurance premium and cost sharing financial support.

But the experience in Massachusetts, which structured its overhaul in a similar way, suggests few will choose to pay the (individual mandate) penalty. There, rates of uninsurance for young adults have fallen to the low single digits. "The idea of paying a penalty and getting nothing is more distasteful than paying more to get insurance," said Gary Claxton, director of the Health Care Marketplace project at the Kaiser Family Foundation.

When the individual mandate took effect in Massachusetts in 2007, we had no idea how it would work or how uninsured folks would react. We had plenty of confident predictions of failure from the Wall Street Journal and other critics. Didn't happen.

"Everybody is having sleepless nights given the magnitude of the effort and the short amount of time," said Kevin Walsh, a senior executive at Xerox working with multiple states on health plan implementation. "It's like building a bridge from both ends and hoping, in the end, they connect."

The system readiness question, especially given the need to link federal and state systems, is among the most worrisome.

Today, Medicare Part D has more than 50 million beneficiaries and is extremely popular. In an October survey, over 90 percent of enrollees described themselves as satisfied. "The temporary issues were just that, temporary," said Mark McClellan, who led Medicare during the rollout. "The memories didn't last that long. In the end, it comes down to how good the insurance coverage is."

And, let's remember, the Republican President, Senate, and House that enacted Medicare prescription drug "Part D" program paid for about 25% of the cost of the law with enrollee premiums, and put the rest of the tab onto the federal deficit -- over $1 trillion between 2010 and 2019. The ACA was fully self-financed, and likely to be even more positive for the federal budget than originally predicted.

Please read Ezra and Sarah's excellent piece.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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