David Brooks: Obamacare a huge mess

April 30, 2013 

It was always going to be difficult to implement Obamacare, but even fervent supporters admit that things are going worse than expected.

Implementation got off to a bad start because the Obama administration didn't want to release unpopular rules before the election. Regulators have been working hard but are overwhelmed, trying to write rules that influence the entire health care sector -- an economic unit roughly the size of France. Republicans have made things much more difficult by refusing to provide enough money for implementation.

Everybody involved is anxious. Insurance companies are trying to put out new products, but they don't know what federal parameters they have to meet. Small businesses are angry because provisions that help them have been put on the back burner. Health care systems can't plan without a road map.

I've been talking with a bipartisan group of extremely well-informed health-care experts, trying to get a sense of how bad things are. A minority, including some supporters of the law, think the situation is a complete disaster. That minority predicts Obamacare will collapse and do serious damage to the underlying health system.

The clear majority, including some of the law's opponents, believe we're probably in for a few years of shambolic messiness, during which everybody will scramble and adjust, and eventually we will settle down to a new normal.

What nobody can predict is how health care chaos will interact with politics. There's a good chance Republicans will use unhappiness with an already unpopular law to win back the Senate in 2014. Controlling both houses of Congress, they will be in a good position to alter, though not repeal, the program.

The law's biggest defenders will then become insurance and health care companies. Having spent billions adapting to the new system, they are not going to want to see it repealed or replaced.

The experts talk about the problems that lie ahead as cascades. First, there is a structural cascade. Everything is more complicated than originally envisioned. The Supreme Court decision made the Medicaid piece more complicated. The decision by many states not to set up exchanges made the exchange piece more complicated. The lines of accountability between, for example, state and federally run exchanges have grown byzantine and unclear.

A law that was very confusing has become mind-boggling. Americans are going to be overwhelmed and befuddled. Many are going to stay away, even if eligible for benefits.

Then there is the technical cascade. At some point, people are going to sit at computers and enroll. If the data process looks like some 1990s glitchmonster, if information doesn't flow freely, then the public opinion hit will be catastrophic.

Then there is the cost cascade. Nearly everybody not in the employ of the administration agrees this law does not solve the cost problem, and recent regulatory decisions will send costs higher. A California study found that premiums could increase by 20 percent for people not covered by subsidies. A study by the Society of Actuaries found that by 2017 costs could rise 32 percent for insurers covering people in the individual exchanges, and as high as 80 percent in states like Ohio.

Then there is the adverse selection cascade. Under the law, young healthy people subsidize poorer, sicker and older people. But the young might decide they're better off paying the fines, if those are even enforced, and opting out. Without premiums from the young, everyone's costs go even higher.

Overall, it is likely that Obamacare is here to stay. But the turmoil around it could dominate politics for another election cycle, and the changes after that -- to control costs, to fix its mind-boggling complexities and the unintended consequences -- will never end.

Regulatory regimes can be simple and dumb or complex and sprawling. When you build complex, it takes a while to work through the consequences.


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