Republicans who are trying to exploit the difficulties with Obamacare’s rollout for political gain are, as usual, getting it all wrong. Those problems with “healthcare.gov” don’t prove what conservatives think they prove. They're an indictment of the Right’s visions of privatization, and of the self-described "political center's" ambitions for Medicare, Medicaid and Social Security.
Lead Republican budget negotiator Paul Ryan says so himself: They want to dismantle Medicare as it exists today and replace it with "Medicare exchanges." Hey, what could go wrong?
That’s why I only partially agree with Bill Scher when he says that “liberal journalists shouldn’t pile on” to criticisms of the healthcare exchange websites. Mike Konczal comes much closer to my own viewpoint when he says that the website’s problems are an indictment of neoliberalism, that “third way” Democratic Party attempt to reconcile the interests of the public with those of deep-pocket corporate and individual donors.
That approach gives conservative Democrats some common ground with the Republicans. But the neoliberal agenda forces its adherents to package social initiatives in Rube Goldberg-like contraptions, in an attempt to reconcile the ideology of the free market and the interests of powerful corporations with those of the public.
How's that working out for you?
Social insurance, Rube Goldberg-style.
The Affordable Care Act was born, as many people know, in the bowels of the conservative Heritage Foundation think tank as an alternative to the health reforms being proposed by Bill and Hillary Clinton in 1993 and 1994. The Clinton initiative was overly complex because it, too, tried to reconcile the needs of private corporations with the need to provide broader health care coverage.
In that sense, therefore, the ACA can be seen as a streamlined version of the Clinton proposal. But even a streamlined version of a program like this is extraordinarily complicated.
What makes the process so complex? First, a variety of individual insurers must be connected with the government exchanges. Second, their bids must all be assembled and presented to the public in uniform and readable form. As one who designed health systems for insurance companies in a previous life, I can tell you: this process is more complicated than it sounds.
But what makes it especially complicated is the fact that, in a certain sense, healthier individuals are expected to subsidize the cost of caring for sicker individuals, which means the success of the entire program rests on the ability to make enrollment as attractive as possible to them.
Quotes that sell.
That’s why it’s become so hard for people to get quotes on the exchanges. The “quick glimpse” of pricing that most people would like to get, without having to submit a lot of information, would only show the amount insurance companies will be receiving for their care.
The systems designers wisely understood that this would drive a lot of people away. The system couldn’t be designed simply to offer raw insurance quotes. The quotes had to be as low as possible in order to seal the deal. (This process also hides the subsidies which insurance carriers receive taxpayers, although that may not have been the intent.)
For this reason, designers only wanted them see the rates they themselves will pay – rates which will often be lower than the “raw” rate, especially for the younger and healthier individuals the program needs to attract.
That complicated set of requirements led directly to the problems were seeing today.
The Republican healthcare exchange.
Yes, the government should have seen these problems coming. And I’m baffled by the fact that nobody has introduced to me what seems like a very quick fix, by allowing people to submit their demographic information in a quick and easy front-end screen which could then be “batch processed” in a day or two. They wouldn’t be kept online, bottlenecks would be relieved, and a system like that is easy to design, relatively speaking. If the government had gotten on it as soon as the problems began, it could’ve been in place by now.
But the real cautionary tale of “healthcare.gov” is one that should disturb Republicans more than anyone else. The Ryan budget – that is to say, the Republican budget – has proposed that all Americans will become eligible for Medicare after the year 2023 purchase that program from private insurers.
Rep. Paul Ryan and the Republicans have a system which seniors can use to purchase health insurance once they've eliminated Medicare as we know it. As Ryan's website points out, they call it a "Medicare Exchange." Republicans had a similar plan for Social Security back in 2005. They intended to dismantle this popular and successful program and replace it with a series of private offerings.
Neoliberalism made complicated.
The neoliberal agenda – which includes the “bipartisan” consensus behind that ever-elusive “Grand Bargain” – believes that Medicare should be means-tested. Means-testing is the process which has caused so much difficulty with the ACA website.
And it is the insistence that we purchase health insurance from private entities which is created all these problems in the first place. Medicare enrollment, by contrast, is quick and relatively simple. It will remain so as long as it doesn’t have means-testing or other neoliberal/conservative restrictions imposed upon it.
This leads us into the category of what Konczal calls “Category A” social insurance programs, conservative/neoliberal inventions which are based on means-testing and complex public/private hybrids. Although neoliberals love to present themselves as “technocrats,” let’s be perfectly clear: these types of programs are ideologically-driven, at least as much as today’s Social Security and Medicare – and perhaps even more so.
Programs like Social Security and Medicare, unlike the neoliberal contraptions which serve as their equivalent, have a long track record of success.
Private sector, public failure.
Lastly, Republicans have used this as an opportunity to rail about the ineptness of the government in administering large – scale programs. That’s where I agree with Scher. Some of the liberal critiques come close to drawing the same conclusion. In fact, government has proven extraordinarily effective at delivering certain types of programs, even in the face of increased spending cuts.
The problem is, government successes are largely invisible to the American people. The processing of Social Security applications, the issuance of Medicare payments, this is the sophisticated analyses of medical costs, fraud, and billing practices that constitute the back end of governments healthcare processing systems – all of these remain hidden from public view.
But conservatives or neoliberals who trumpet the private sector’s supposedly efficiency in these areas need to explain to the American public why they have so much difficulty with private insurance’s administrative processes.
How many of the people who are attacking the ACA website today have tried to call their health insurance company to get a simple question answered? Nowadays that task can involve many minutes or even hours on hold, and an endless series of baffling and frustrating voice response menus which are eventually followed by an unsatisfying interaction with an uncooperative employee.
We won’t even talk about what it takes to get a claim paid.
Neoliberals, beware. You need to think less about placating corporate sponsors and reflect more on that old adage: If it ain't broke, don't fix it.
And be careful, Republicans! Every critique you offer against the ACA rollout is a damning indictment of your ideology of privatization and your vision for 'reforming' Social Security and Medicare. Whether you want to call the customer service line at your private health insurer, or are eager to slam the healthcare.gov website for partisan reasons, our advice to you is the same either way:
Don’t go there.