Obamacare Forever?

What Barack Obama’s second term means for the president's signature health law.

Since debate about health care reform began, voters have been consistently wary of the law that has become known as Obamacare; as of today, Pollster.com’s aggregate shows that 47.8 percent of the public opposes the law while just 39.2 percent approve. Yet in voting to give President Barack Obama a second term yesterday, America also implicitly voted to keep the health law that bears his name in place. So is Obamacare here to stay?

Yes, at least for now. But big questions still remain. We know we’ll keep Obamacare on the books, at least for the foreseeable future. What we don’t know is whether it will work.

That’s because the law still faces huge legal and logistical hurdles. Tops on the list are challenges to the law’s insurance exchanges, starting with a lawsuit filed by Oklahoma’s attorney general. That case, which revolves around legal problems examined in a paper by Case Western Reserve law professor Jonathan Adler and Cato Institute Health Policy Direct Michael Cannon, may decide whether employers in states that do not set up their own health insurance exchanges can be taxed under the law, as well as whether it is legal for the federal government to offer insurance subsidies through exchanges it runs in states that opt out. The law, which taxes employers that don’t offer insurance in order to fund those subsidies, states that subsidies are only available in state-run exchanges.

If Oklahoma’s suit prevails, states will have a large incentive to opt out of creating exchanges in order to protect employers from the tax penalty. And the federal exchanges will be largely useless. “No one would go to those exchanges. The whole structure created by the health care reform law starts to fall apart,” Gretchen Young, senior vice president-health policy at the ERISA Industry Committee told Business Insurance.

The federal government faces other challenges to setting up its own exchanges as well. For one thing, there was no money appropriated to build the federal exchanges. Perhaps money can be found, but so far no one knows where. One adviser charged with helping Department of Health and Human Services create those exchanges has admitted that in order for HHS to build the exchanges, the federal government will likely have to “get creative about the financing.” Implementation so far has been secretive and shoddy. Just this week, reports surfaced noting HHS may have improperly failed to disclose conflicts of interest in contracting with private insurers to help run the exchange. 

The law’s state-run exchanges aren’t exactly proceeding as planned either. As of October, eight states have said they will not create exchanges at all. Many others have chosen to wait to begin the process. Less than a third of the states have definitively chosen to establish exchanges. And even those states actively trying to implement the law are having a tough time. California has faced delays and the likelihood of large premium hikes. The law says the exchanges are supposed to be ready for federal certification by the beginning of 2013. But the District of Columbia’s acting director of health reform, who is working to implement the law, told The Washington Post that, “No state is going to be able to be fully certified on Jan. 1. When they passed the ACA, they were highly optimistic about the timeline for states to implement exchanges.”

Highly optimistic is one way to put it. Delusional might be another. Those who oppose Obamacare are going to have to learn to live with the law. But those who support it are going to have to learn to live with its inevitable failures.

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  • Pro Libertate||

    Kill it, please. Thank you.

  • R C Dean||

    What we don’t know is whether it will work.

    Actually, I'm pretty sure we know it won't, if "working" is defined as controlling costs, increasing the number of people with insurance in any meaningful way, opening up access to actual health care providers, making people healthier, or any of the other things it is supposed to do.

    Now, will it result in disruption, expense, and ample anecdotal horror stories paving the way for further government takeovers? You bet. So in that sense, it will work just fine.

  • ||

    Ideas for improving the law:

    1. Allow catestrophic-only plans to qualify.
    2. Add long waiting periods to cover pre-existing conditions (Massachusetts does this).
    3. Nullify the mandate by having states reimburse residents who incurr the penalty via a refundable tax credit on state tax returns.
    4. Cut the subsidies.
    5. Add more room for insurers to vary rates according to risk.
    6. Add legal distinctions between "actually having cancer" and "has a high risk of cancer" to the guarenteed issue provision. Allow insuers to not insure the "actually having cancer" category and boot them to the "high risk pools".
    7. Eliminate the "free preventive care" bit and replace with standard co-pays. Allow catestrophic only plans to not cover preventive care below the deductibe.

  • Ken Shultz||

    Who, over the next four years, is going to make these improvements?

    Obama?!

    Where do these magic people come from, that come out of nowhere and make changes to what Obama wants?

    Even Boehner wants to raise our taxes to address the fiscal cliff now! He stood firm for what--20 minutes?!

    Who is going to make improvements to the law--if not Obama? I apologize if these seems harsh, but I think some of my fellow libertarians are living in a fantasy world...

    ...a world where public policy gets changed at the national level--in spite of what Obama wants. That world is gone for at least two years--probably four. We live at Obama's mercy now.

    There will not be any changes to public policy unless Barack Obama approves of them--for the foreseeable future.

  • ||

    Item 3 is up to the states.

    Item 1 could easily be done when (not if) there is a popular backlash at the expensive insurance policies people are being forced to buy. A LOT of people are not going to be happy with their insurance rates, and it's much easier to lower the minimum requirement than it is to raise the subsidies.

    Everything else could be part of a compromise debt deal.

  • Ken Shultz||

    Okay, I'm on board with #3.

  • Len Bias||

    Item One will be fought tooth and nail, especially in our current environment, where not having the government pay for your birth control is seen as a return to the dark ages.

    The response to higher premiums will be more subsidies and more regulatory oversight over the "price-gouging" insurance companies.

    I'm just not feeling optimistic about the las being undone any time soon.

  • ||

    It's going to be hard to increase the subsidies when (a) we have an exploding budget deficit, and (b) Republicans control the house, and (c) people are required to spend the money anyway, suckers.

    Plus, many people who sign up for high-deductible plans not realizing they don't qualify, and end up getting slapped with the penalty and get pissed off. And consequently there will be a lot of pressure to let those plans qualify. Lowering the "mandatory minimum" ought to be the easiest reform of the bunch.

  • Len Bias||

    I hope you're right.

  • Ken Shultz||

    Will it work?

    You mean as a massive tax hike?

    Of course it'll work!

    Will it put millions of more people on Medicaid rolls at the expense of taxpayers?

    Yes!

    So, of course it'll work. And if it doesn't? They'll just push through some more of the same.

    You're acting like there's some alternative to whatever Obama wants. It's like when Wiley E. Coyote looks into the camera before he falls off the cliff. We're like in that instant between when he goes off the cliff--and when he realizes that he's falling off the cliff...

    Seriously, Suderman, what difference does it make if ObamaCare doesn't work? What can ANYBODY do about it if ObamaCare doesn't work?

  • FD||

    "Seriously, Suderman, what difference does it make if ObamaCare doesn't work? What can ANYBODY do about it if ObamaCare doesn't work?"
    And to your initial point, what the hell does "will it work" mean, anyway?
    This is where even libertarian journalists are naively suckered into the statist paradigm. Once the state has you conversing on their terms, discussing workability on macro perceptions, you're done. Work schmork. Step away from the trees for a minute; what is the only way to advance liberty? Armed revolution or... you must starve the beast and find ways to chip away at all the dreadful components. One could even use HazelMeade's list above in isolating the battlefields. Exception by exception, you got to tear away at the shawl and shred it slowly.

  • Ken Shultz||

    I think the illusion of having some say in the matter is part of the problem.

    We need to embrace our helplessness.

    Abandon all hope.

    We're not going to influence public policy at the national level. The Republicans don't even really have any say at the national level! What chance do libertarians have...

    There is a third way to change things that you didn't mention...

    1) Revolution
    2) Starve the Beast

    3) Evangelize!

    If we can't impact public policy, we can try to change people's hearts and minds. That's why Ron Paul and the LP are often such a distraction from our real mission. In the words of Brian Doherty (I'm paraphrasing), the purpose of libertarianism has always been to create more libertarians. And that's our best hope.

    We have four years to evangelize and create a more libertarian electorate. In the meantime, we're gonna get raped and abused. We have no influence or control on public policy. We need to accept that and start working on the things we can do to convince other people to become more libertarian.

  • ||

    I'm with Ken on this. Playing electoral politics is never going to work if the majority of the public genuinely is made up of people who are dependent on the state and want more free shit.

    We have to teach people how to be independent again.

  • Government Hack||

    I think there are several lessons to learn about cultural change in To Change the World (Oxford, 2010).

    The basic thesis of the book is that cultural change happens when a group of elites at the center of power work together toward a common purpose.

    The author spends a lot of time (successfully) critiquing the Evangelical method of "moral majorities," showing how such approaches to cultural change are doomed to failure. He also argues that creating your own sub-culture does nothing either.

    He's pessimistic about the ability of people to deliberately change culture, but basically you need people with your ideas in the best universities, writing at the best newspapers, working in the best companies and generally everywhere that institutions of cultural dominance exist.

    So I think libertarians need to do just that. It will take a generation or two, but it can work.

    My only warning is that "hearts and minds" evangelism was tried by the social conservatives for a long time--and failed.

  • Len Bias||

    "Highly optimistic is one way to put it. Delusional might be another. "

    How about apathetic as to its consequences and inevitable failures?

  • tagtann||

    Come on man that makes a lot of sesne dude. Wow.

    www.post-anon.tk

  • KalkiDas||

    Sorry, I don't usually cuss, but I had a gin and tonic. Yes, it will fucking fail. It was designed to fail, on purpose, the steaming heap of corporatist shit that it is. And guess what will come to the rescue? Nationalized healthcare. The reason given "uh, we uh, tried the uh, free market, but it uh, failed" or I suppose I should use some progressive bob-haircut witch voice instead of Obama because it'll be more than 4 years out.

  • Will Nonya||

    Well obviously if they had been allowed to read it before they passed it they might not have been so optimistic.

  • π-e||

    what the statue of liberty should say: "Abandon all hope, ye who enter here"

  • Epicdelusion||

    Want to know what to expect with Obama? Here's how you do it... pay attention to what is happening with private insurance companies today. What are incentives now will become law. For instance, Cygna Health now lowers insurance costs for people with slimmer waist lines and whom have less bodyfat percentage. The incentive used to be for smokers (and still is in some cases) before sweeping smoking bans and legislation stormed in. What's going to happen next is the government will begin making it illegal to be out of shape. The justification? Your health is now the business of every tax payer who will not want you to smoke, drink, do drugs, fuck diseased bitches, eat a cheesesteak and sit around all day doing nothing. Get ready for government exercise programs. 1984 is upon us.

  • XM||

    My prediction - lots and lots of people won't buy healthcare, period. As I understand the law, (for all intents and purposes) the IRS or the government cannot throw people in jail for refusing to buy insurance. The IRS could theoretically sue, but that's political suicide for someone.

    I've heard some grumbling at the local Asian circle about the government making them pay for medicare AND their own insurance. These guys probably voted for Obama.

    Obamacare was destined to happen. Its effects has to be felt in real terms outside of policy debates. Obama must have been more of rock star than previously imagined, because all of my friends who are pharmacists and nurses are convinced O-care will complicate their jobs in hideous ways, but some of them voted for him anyways. Working 40 hours without sleep will change their tune.

  • Ken Shultz||

    "As I understand the law, (for all intents and purposes) the IRS or the government cannot throw people in jail for refusing to buy insurance."

    The IRS can all sorts of horrible things to you without throwing you in jail.

    Including garnish your wages, which is devastating to people who are living from paycheck to paycheck.

    I take no solace in the suggesting that the IRS can do all the things it normally does--except throw you in jail.

    Unpaid taxes will continue to accumulate, over the years, and the back interest due will still continue to compound. The IRS can still seize bank accounts and your personal property.

    Not being able to throw people in jail isn't much of a consolation. They'll still ruin people's lives anyway.

  • Government Hack||

    Not to mention being audited for doing nothing at all. What a nightmare.

  • ||

    What would make a bigger stink is purchasing a catestrophic-only plan and then making it a very very public court case when the government tries to collect the fine anyway.

  • Ralph Wylie||

    This is probably a question for Google, but are Muslims and Christian Scientists or other religious groups exempt from participating in Obamacare? If so, I am converting (on paper) for the obvious reason of freedom from participating in the sham that is Obamacare.
    BTW, I have health insurance now and don't want anyone messing with it. I qualify for Medicare now and didn't sign up for it. I'll gladly pay my own way.......thank you.

  • Sevo||

    Ralph Wylie| 11.8.12 @ 5:55PM |#
    "This is probably a question for Google, but are Muslims and Christian Scientists or other religious groups exempt from participating in Obamacare?"

    I sort of doubt G has that figured, nor does Wiki. That question is probably gonna rattle around the courts for years.
    But as an atheist I'd be willing to lie through my teeth.

  • Government Hack||

    Maybe there is some sort of precedent with the Mennonite tax exception.

  • truthisnotrelative||

    How does that "principled" vote for Gary Johnson taste?

  • Government Hack||

    I remember walking into the booth resigned to a stink vote. Obama and his fawning acolytes deserved to lose. But as pushed the button for Romney, I felt an almost irresistible urge to vote for Johnson.

    I should have voted for Johnson anyway. I'm not even in a swing state and the smaller bigger government alternative lost anyway.

    So I regret my un"principled" vote.

    How's that?

  • Rick Santorum||

    Romney would not have won, and he would not have repealed Obamacare even if he had.

  • CZmacure||

    I think Obamacare was always designed to fail. It's a Trojan horse for a public system. And that's why I support it. And so should you supposed rational empiricists on reason.com. Look at literally every other industrialized country on the planet: they have it, they like it, they pay less, it works. Profit motive isn't always the solution to every problem. Sometimes it creates a ridiculous conflict of interest that benefits only a handful. Be reason-able.

  • ||

    First of all, not everyone in those countries like it. Secondly screw following Europe and any of their fiscal insanity. Thirdly, long waiting times and refusal of care by some faceless bureaucrat sound like pretty shitty things to me.

    And finally: FUCK OFF SLAVER!

  • Rick Santorum||

    Thirdly, long waiting times and refusal of care by some faceless bureaucrat sound like pretty shitty things to me.

    Lol, repeating Republican talking points. Universal health care works better than our private-public mixed system. Chances are, if we had a free market system, we would have relatively inexpensive health care and more medical innovation, but we don't have that. And, unfortunately, we were stuck with two options for reform.

    (a) Obamacare.

    (b) Fuck off, you should have been born into a wealthy family or gotten a fat defense contract or been one of the bankers who screwed America. You deserve to starve in the streets for having cancer. Keep your big government librul hands off my Medicare.

    Americans decided they wanted something rather than nothing. Sucks for those of us who are aware of the history of rising health care costs in America, but them's the breaks.

  • Rick Santorum||

    I think Obamacare was always designed to fail. It's a Trojan horse for a public system. And that's why I support it.

    You are scum. You are willing to deceive the public and take a shit on everyone else to get what you want.

    BUT IT'S FOR THE GREATER GOOD, you say. Reminds me of Lenin's "Who? Whom?"

  • pradaguccioutlet@gmail.co||

    If Oklahoma’s suit prevails, states will have a large incentive to opt out of creating exchanges in order to protect employers from the tax penalty. And the federal exchanges will be largely useless. “No one would go to those exchanges. The whole structure created by the health care reform law starts to fall apart,” Gretchen Young, senior vice president-health policy at the ERISA Industry Committee told Business Insurance.

    The federal government faces other challenges to setting up its own exchanges as well. For one cheap nfl jerseys thing, there was no money appropriated to build the federal exchanges. Perhaps money can be found, but so far no one knows where. One adviser charged with helping Department of Health and Human Services create those exchanges has admitted that in order for HHS to build the exchanges, the federal government will likely have to “get creative about the financing.” Implementation so far has been secretive and shoddy. Just this week, reports surfaced noting HHS may have improperly cheap nhl jerseys failed to disclose conflicts of interest in contracting with private insurers to help run the exchange.

  • pradaguccioutlet@gmail.co||

    Lol, repeating Republican talking points. Universal health care works better than our private-public mixed system. Chances are, if we had a free market system, we would have relatively inexpensive health care and more medical innovation, but we don't have that. And, unfortunately, we were stuck with two options for reform.

    (a) Obamacare.

    (b) Fuck off, you should have been born into a wealthy family or gotten a fat defense contract or been one of the bankers who screwed America. You deserve to starve in the streets for having cancer. Keep your big government librul hands off my Medicare.

    Americans decided they wanted something rather than nothing. Sucks for those of us who are cheap nfl jerseys aware of the history of rising health care costs in America, but them's the breaks.

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