A Hack Idea Whose Time Has Come: I admit that all the recent Obamacare troubles are … well, let’s face it, they’re huge fun.
It’s true, I supported Obamacare–I favor universal health care, and still think it’s a good idea to try to inject competition through the “three legged” mechanism** of the exchanges before resigning ourselves to some kind of Medicare-for-all scheme.
On the other hand, it’s hard not to witness the current Obamacalypse without getting more than a little spark of serotonin. Here’s the self-righteous, cocooning, progressive “coalition of the ascendant,” disdainful of triangulation, dismissive of all the 90s-era Charlie Peters neolibs with their worries about bureaucracies and perverse incentives and their focus on the mechanics of government, suddenly discovering that neglecting the mechanics of government can be a big, big mistake. The Education of Ezra Klein continues, at great expense to the nation. We might as well enjoy the spectacle.
But I know I should be constructive! That’s not easy. The reaction of most of Obamacare’s defenders–denial and scapegoating–is quite understandable, given the gravity of the situation. Even if the website is fixed, it’s pretty clear, Obamacare faces a tough two to three years at best. The enrollment targets will not be met, setting up an ‘adverse selection’ problem (because sicker, more expensive people will be the ones who do sign up). Built-in-fail-safe subsidies in the statue may prop up money-losing insurers and stop this from turning into a full blown death spiral, but the main fail-safe subsidy expires at the end of 2016. Either the exchanges will have a healthy mix of enrollees by then, or else the bailout will have to be extended, or else ….
Plus there’s the separable, political question of whether the unsubsidized “losers” on the exchanges–the Shocker Moms***–will stand for taking the hit they’re taking in order to support the ACA’s “winners.” And that’s separable from whether anyone will like the restrictions on choice of doctors that so many insurance companies seem to be promoting. Worse, voters are facing this three year gauntlet without much apparent confidence in the ability of the administration to make it better. After all, the people in Obama’s White House are, as Obama used to say about Bush, the ones who made the mess.
So here is a constructive idea:. Appoint an ongoing high-level
multi-partisan**** Obamacare Review Commission to monitor the rollout of the exchanges and recommend significant fixes. This commission could issue periodic warnings–this software project isn’t going fast enough! Death spiral at 3 O’clock! CMS staff isn’t up to the job!
More important, it could push major policy changes designed to make the whole contraption function : Most obviously, it could suggest that the list of mandated “essential benefits”–including maternity care and pediatric dentistry–be pared back, which would lower “sticker shock” for all. It could advocate rejiggering the subsidy system–after all, why should merely non-poor customers in the individual market ($46,000 a year and up for singles) bear so much of the cost burden of insuring those with preexisting conditions? If those unsubsidized “losers” are really only 3% of the population, as depicted on that famous chart–well, which way does that cut? Maybe it suggests the A.C.A. exchange system isn’t very fair after all, screwing a tiny un-rich minority to benefit a larger group.
Maybe everyone stuck in the individual market should get some subsidy–$100, $200, $400–financed by tax dollars. Maybe the lucky 80% or so with employer plans should pay more than the current system asks. Maybe de facto temporary subsidies of the insurance industry should be made explicit and permanent. Maybe insurers could be jawboned into expanding their doc networks. Maybe penalties for not buying insurance should be made stronger and more automatic. Maybe we should junk the whole apparatus and expand Medicare.
I don’t know. I’m not an expert. That’s why you need a commission.The idea would be to give the public confidence that someone other than the panicked, bunkered, politicized, and certifiably not-up-to-it White House (or the equally politicized GOP opposition) has an eye on the long-term outcome.
Wouldn’t this just be another useless Blue Ribbon Commission? It depends. Suppose it were headed by Bill Clinton and (longshot) Mitt Romney. If they said, hey, you’ve got to cut down on these expensive mandated benefits in order to save the exchanges–well, I would think Democrats, and some Republicans, would be hard-pressed to resist that change.
The bigger obstacle would be Obama’s ego. In effect, he’d be saying he’d lost control over his most important program, or at least that he’d lost the public’s trust. That would be true. But it’s true whether he appoints a commission or not. And surely Dan Pfeiffer could spin it as a way to free up the President to focus on other duties–foreign policy, in particular. Global warming treaties! Delicate negotiations with Iran! That’s the ticket.
Not an original plan, I admit, or a guaranteed solution. I normally hate commissions. But desperate times …
You got a better idea?
**–Obamacare’s three-legged stool: 1) guaranteed issue (despite preexisting conditions), 2) mandate to buy coverage, 3) subsidies to help people pay the now-increased premiums for the mandated coverage.
***–Suggested by alert tweeter @psmith867
****–Making the commission officially “bipartisan” isn’t especially useful. “Bipartisan” is itself a tarnished brand these days–it’s come to mean little more than “represents the view of the permanent DC establishment.” The key is that the commission be independent of the day-to-day White House operation (including the day-to-day administration of Obamacare). It would also be good to get some buy-in from the architects and advocates of Romneycare, including Republicans.