In 2014, millions of individuals across the country are projected to begin receiving health insurance subsidies. But the process of determining who gets those subsidies, and how much an individual is entitled to, is going to be enormously complicated. For a sense of just how complicated, see health care consultant Roger Collier, who lays out the basic steps. The short version? It’s a multipart mess, even when it goes well. And there will probably be a lot of boundary cases in which the process becomes even more confusing. What happens when individuals fill out the application forms wrong? Or too close to the deadline? Or when information gets lost in the multiple mandatory paper shuffles between agencies?
If you followed the political process of passing the health care law, though, this shouldn’t come as a surprise. Because of the messy politics that helped create it, we ended up with a lot of policy mess in the legislation. Collier notes that the how-to-get-a-subsidy section accounts for about 25 pages in the bill’s 2,000 pages. In addition to subsidies for private insurance, states managing the exchanges will also have to determine Medicaid eligibility, and whether (and how) to kick a subsidy applicant over to the newly expanded low-income health insurance program. It’s not for no reason that states are publicly fretting over the technical complexity of building the health insurance exchanges.
I know that critics of the law have focused a fair amount of attention on the simple fact that most of the legislators voting for the law didn’t read it (though given the use of frequently-inscrutable legislative language, I’m not sure how much good that would have done). I know that Nancy Pelosi’s declaration that we’ll have to pass the law to find out what’s in it has become a mantra for those opposed. But even still, I suspect folks are underestimating the bureaucratic complexity involved in both the implementation stage and the eventual ongoing management of the subsidies, the insurer regulations, the Medicaid program, and the rest of the bureaucratic apparatus. As the Congressional Research Service reported over the summer, the law is so byzantine that it is impossible to estimate the number of new bureaucratic entities that will end up being created by the law. It’s a bureaucratic black hole: Who knows how deep it goes, or where it leads? As we go forward, this will likely make things difficult for state officials in charge of running the non-federal parts of the program. And it will probably result in numerous complications for some number of the individuals who end up on the exchanges. It’s yet another area of the current health care system that the new law has taken and arguably made worse. For many folks, health insurance is already a serious headache to deal with. But the PPACA just adds new layers of bureaucracy to the system.
On the other hand, maybe the folks who voted for the law decided that building a great big bureaucratic Rube Goldberg was the only way to one-up OK Go: