MedSmarts

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Obamacare’s Core Failing Is Its Timidity

A Bigger, Bolder Obamacare Was Needed

A recent article at MedPage Today reported on an expert discussion about Obamacare’s critical need to repair its online portal at healthcare.gov so those Americans wishing to purchase qualified health plans on the exchange can do so by December 1st. This would leave them only two weeks to secure coverage by December 15th (note: this deadline’s been extended to December 23) in plans that would take effect on January 1st, 2014 – when Obamacare formally takes effect.

The forum for this was the esteemed Center for Studying Health System Change’s annual “Wall Street Comes To Washington” conference in which Wall Street analysts weigh in on the latest trends in American healthcare. Obamacare was the obvious choice for the hot seat this year and there was no shortage of dire predictions about what will happen if the bungled Obamacare website roll-out at healthcare.gov isn’t fixed by the end of November.

The big fear is that only the sick and infirm will be motivated enough to persevere through whatever hurdles remain, leaving the insurance pool with too few healthy subscribers to subsidize the increase in less healthy subscribers. This, of course, will cause next year’s premiums to rise more than if there were a better balance of less healthy and more healthy people in the pool. It’s Insurance 101 – or what Obamacare’s opponents call “socialism”.

Maybe MORE Uninsured?

Even worse would be the scenario in which the site’s problems aren’t fixed in time for the required December 15th enrollments while millions have had their prior “sub-standard” plans that didn’t meet Obamacare’s requirements cancelled. In that scenario, they’d join the ranks of the uninsured.

Not only is that the opposite of what Obamacare intends, it would also spell doomsday, as some perceive it, for those Democrats in Congress in swing states who are up for reelection in 2014. They, in turn, might abandon Obamacare’s cause and join ranks with those on the rabid right hell-bent on repealing it.

Team Obama has, regrettably, played right into their hands. Just when it looked like they had cunningly outfoxed Republicans over their ill-advised government shutdown and debt ceiling fiascos, we learn that the White House crew isn’t as facile at actually managing things – including its signature program that will be its legacy, for good or ill – as they are with the political stuff.

From the MedPage Today article:

“With meager enrollment, the ACA’s issues around narrow provider networks may only worsen. Hospitals, at least, are working with exchange plans in hope that patient volumes will increase over time and then they can go to plans and get better prices. If patient volumes aren’t high enough, providers such as hospitals may opt to not participate at all…

“‘What if they give a party and nobody comes?’ Sheryl Skolnick, PhD, managing director of CRT Capital Group in Stamford, Conn., asked. ‘Now you’ve got yet another problem, which is not just that you can’t get the members on. Now you only have a few plans.'”

Should this be what ultimately unfolds, there’d be too few plans and too few providers for Obamacare to prove viable. It might still survive as some sort of sub-standard healthcare option on the order of Medicaid where access is limited because many doctors won’t accept its lower payments for their services. But that isn’t what anyone originally envisioned – nor would it be considered a success.

It’s the next and closing thought in this report that most caught my attention…

“The root cause of these potential problems — the buggy HealthCare.gov — must be working well in the next couple of weeks, they (the Wall Street analysts) said.”

But the buggy website isn’t really the root cause of Obamcare’s doldrums, is it? It’s more the proximate cause – along with the mishandling of the junk policy cancellations and insurance plans that are skimping on provider networks and low-balling doctors and hospitals with Medicaid-level rates that many will reject.

It’s what Jeff Green of “Curb Your Enthusiasm” would call “A whole bowl of wrong”.

What IS the Root Problem?

So if the website fiasco isn’t Obamacare’s root problem, what is?

You have to go back to its original design – back to the days of a freshman Obama administration that miscalculated the political resistance our first black president would receive to virtually ANY of his initiatives.

Did they not believe Senate President Mitch McConnell when he said, on the day Obama was sworn in, that he’d do everything in his power to obstruct him and make him a one-term president?

Did they not get that the campaign to discredit the president and undo his very election was their opponents’ singular mission and that no amount of extending the olive branch of compromise would bear fruit?

They obviously didn’t, opting instead for the naive strategy of attempting to appease them by cobbling together a hodgepodge of “reforms” that may have been too clever by half – soon to be labeled by their enemies as “Obamacare”. The idea was to emulate the Massachusetts’ prototype for health insurance reform – as opposed to health system reform – that relied on expanding the private markets of insurers and providers with mandated insurance coverage.

This was a Republican idea first offered by the conservative Heritage Foundation to rid society of all the free-loaders – they call them “free-riders” – who weren’t buying health insurance but relying instead on “the kindness of strangers” paid for with higher premiums for everyone else.

That worked OK in Massachusetts – though it hasn’t resulted in any health system reforms that are long overdue, so success is a relative term.

But Massachusetts didn’t have the fractured politics that’s escalated so ferociously since Mr. Obama became president. Those on the rabid right blame him for that – it does coincide with his becoming president, after all.

They’re purposely, of course, mixing causation with correlation. The fevered animus we see now on the right may correlate with Obama’s term, but it’s not caused by it.

It’s caused by their confederate concerns about his skin color. It’s packaged not in racial terms, of course – it’s everyone else that’s playing the race card. For them, it’s about him being a socialist.

He’s a damn poor one if he is, given that Obamacare expands the private healthcare sector – anathema to real socialists.

So if the socialist claim is B.S., what’s it a smokescreen for if not racism?

Obamacare’s Branding Problem

It was Obama’s failure to recognize such deep-seated hatred for what it was – perhaps too encouraged by his election victory or his prior success winning in a white man’s world – that led him to adopt an overly-complicated and under-powered melange of measures that were destined to falter for a multitude of reasons:

  • It’s hard to sell complex – Simple lends itself to bumper sticker slogans and successful branding far better than the complex (remember Hillarycare?);

  • It’s hard to implement complex – See healthcare.gov;

  • It doesn’t poll well – All the polls show the public doesn’t really “get” Obamacare – they love some of its provisions and hate others; overall, more dislike it than support it because of its poor packaging and branding;

  • It actually was never properly branded – The “Affordable Care Act”, or ACA, has Washington written all over it, while the “Obamacare” tag that’s gained more traction was a negative Republican moniker to which Obama conceded;

  • It had too few champions – Virtually all of its many players remain conflicted about Obamacare, and relying on those with multiple agendas and conflicts of interest to implement your program is a recipe for failure;

  • It was too moderate – Despite claims by opponents of a government takeover of healthcare – a charge that would have been made for any plan he offered – Obamacare reeks of moderation, without seriously addressing critical health system dysfunctions that are essential to true reform like…

    • Medical malpractice – Defensive medicine continues to plague the practice of medicine in America…

    • Fee-for-service payments – The “piece-work” mentality encouraged by fee-for-service payments continues to drive medical over-treatment that increases spending and medical errors…

    • Over-consolidation – Obamacare actually encourages provider consolidation that gives them more bargaining power to dictate higher healthcare prices.

The inherent timidity of Obamacare is what’s most responsible for its failings to date, aided and abetted by the incomprehensible failure to effectively manage the program’s launch. The fundamental rules of Management 101 seem to have been cast aside – or maybe they were just never learned in the first place.

Perhaps it was hubris – a roomful of Harvard types with too many MDs, JDs and PhDs and too few MBAs to point out the management hurdles to implementing such an ambitious and convoluted program. Amidst all the charges of having too many “czars”, how on earth did they fail to appoint a czar for their most critical priority?

Why Bolder Was Better

All of this could have been avoided – the needless complexity, the reliance on less-than-reliable partners for execution, the exchange problems – with a simpler and, yes, more radical program called single payer, or Medicare-for-All.

Could its Republican/Tea Party opponents have screamed any louder about socialism and government takeover than they do now? Why not give them the real thing – not that Medicare-For-All would really be socialized medicine, since it would still rely on private sector doctors and hospitals. But it’d be called that anyway – hell, Obamacare’s the antithesis of socialism and it’s called that anyway.

So if you have to fight the PR campaign against the right’s charges of socialism, you might as well be fighting for something that might actually get the job done.

It’d have been far easier to sell to a skeptical and torn public. Medicare’s popularity would have provided a solid public opinion foundation. And don’t forget, this same crowd of nay-sayers called Medicare socialism back when it was being introduced, too.

But Team Obama wasn’t even able to stick with its “public option” – a watered-down scenario in which consumers could choose to stay with a private insurer or select a government-run Medicare-like health plan. That was roundly decried as inserting unfair competition into the insurer market. Medicare-For-All would have eliminated the private health insurer market altogether – something many other developed countries seem to get by pretty well without.

Ignoring the People’s Wishes

They’ll say they “didn’t have the votes” for a more ambitious healthcare agenda. And they didn’t. But smarter polling management might have persuaded the fence-sitters in Congress that a Medicare-based reform was too popular for them to resist – it polled with majority support, something Obamacare’s yet to achieve – and pressured them from the left.

It was still Obama’s honeymoon period and he failed to use that to its maximum benefit. And he failed to follow the will of the majority of Americans in doing so – all to placate those whose agenda was rejected with his re-election victory. And how much harder could it have proven to pass legislatively than what they endured getting this weak-kneed alternative passed?

And all the website nonsense would never have happened – Medicare.gov is far simpler and works pretty darn well, with no need to link to private health insurers or to the IRS to confirm income eligibility like healthcare.gov must do.

Oh, and those 5 million Americans they thought would be eligible for Medicaid under Obamacare only to have the Supreme Court make it optional and now almost half the states are rejecting? That wouldn’t have been a problem either, since they’d be eligible for Medicare-For-All – a federal program like Medicare that wouldn’t need state cooperation to be fully implemented.

So while the right is cackling anew about how they “Told us so” about how Obamacare wouldn’t work – which may still prove wishful thinking – the left, what there is of it, can say it with less hypocrisy.

Medicare-For-All is still the only viable solution to America’s healthcare spending crisis.

Even those whose financial self-interest would be decimated were that to occur will acknowledge this in private.

It’s precisely because it would decimate so many financial interests that it would save the country money. Cost-savings don’t come out of thin air – they’re somebody’s income or profits.

And because they have those financial interests at stake, they aggressively fund whatever’s needed to protect those financial interests. No industry in America spends more on political lobbying and campaign contributions than its healthcare industry – and that’s before the Koch brothers and other ideologues add their gazillions to the cause.

In the age of Citizen’s United – when Merck and Pfizer have the same free speech rights as you and I – money talks now more than ever in American politics.

It’d be naive to think that this didn’t impact the shaping of Obamacare – assuring its inherent weakness while planting the seeds for its resistance that continues to this day.

Coming Up Short on Boldness & Bravery

Obama inherited a nation teetering on financial collapse when he took office in 2009, not unlike the fiscal condition that allowed FDR to pull off Social Security or the post-traumatic political environment after JFK’s assassination that allowed LBJ to pull off Medicare. These were comparable strategic moments in American history.

But his opponents’ unrelenting campaign to hang him with the ropes of socialism, birtherism, and “other-ism” effectively neutralized his ability to rise to the occasion as Roosevelt and Johnson had done before him. They weren’t hampered by race or racism, of course, and Johnson had decades of legislative arm-twisting experience to enhance his success.

Nor were their opponents able to leverage their numbers with an internet, cable TV, and hate radio to amplify their message, spread disinformation, and foment hatred on today’s scale.

Had Obama been white, his path would have been so much easier. Had he been Saul Alinsky himself – the much-maligned Godfather of community organizing he’s accused of emulating – his path would have been much easier.

But he isn’t, and he wasn’t, and we live now with the consequences.

It’s worth remembering, however, that his path would probably have been much easier as well had he and his advisers been bolder, and braver – and less politically calculating – when it came to shaping the health reform program on which they decided to rest their legacy.

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