Health care reform

ObamaCare's Big Problem: Where's the Buy In?

One sign of a workable, successful program is that it attracts the participation of outside parties and partners.


One sign of a workable, successful program is that it attracts the participation of outside parties and partners. ObamaCare was designed to work with organizations across the health spectrum: Health providers, state governments, individuals. But so far, it's proven harder than most anyone expected to find willing participants.

Last year we saw the law's administrators struggle to gain support from crucial providers in ObamaCare's ACO (Accountable Care Organization) pilot program. The law encouraged the formation and operation of ACOs—large, highly coordinated health provider groups—based in part on the experiences of a number of well-regarded health systems across the country: organizations like the Mayo Clinic, the Cleveland Clinic, Geisinger Health System, and Intermountain Healthcare. The problem? Those clinics—the models on which ObamaCare's ACO rules were designed—declined to participate in Obama's ACO pioneer program. One reason, according to statements from several of the organizations, was that the law's proposed ACO rules were too restrictive and too prescriptive.

This week we're seeing that model provider groups may be wary of more than just the law's ACO program. Utah's Intermountain Healthcare, a 23-hospital system which President Obama cited in 2009 as a model health organization for its high quality care and below-average costs, has expressed strong reservations about the law's Medicaid expansion, which is expected to provide as much as half of the law's coverage expansion.

Kaiser Health News reports that Intermountain participated in a letter by the Utah Hospital Association (UHA) declining to endorse the law's state-driven Medicaid expansion. There are still too many "practical and political questions around the full expansion that have yet to be answered," a spokeperson for Intermountain told KHN.

Earlier this year, the Supreme Court ruled that states could decline to participate in the Medicaid expansion without risking existing Medicaid fund. The letter from the UHA gives Utah's legislators good reason to be cautious. It notes that if Utah decides to implement ObamaCare's Medicaid expansion, the cost over the next decade is projected to come in at $1 billion. UHA president Robert Betit told KHN that the expansion "could be difficult for the State to sustain in the years ahead."

This is a bad sign for ObamaCare's stability and workability. Model private providers are opting out of the law's ambitious delivery system reforms. Other providers are expressing great skepticism about a major part of the law's coverage expansion. This does not strongly suggest that ObamaCare is shaping up to be a healthy, successful program.

It's not just private providers either. Like Utah, other states will have to decide whether to participate in the law's Medicaid expansion. They will also have to decide whether to create insurance exchanges. And the law is running into significant resistance. Cato Institute Health Policy Director Michael Cannon notes that 14 states have made it illegal to operate an insurance exchange.

Even amongst states that have not outlawed exchange creation, there is little strong desire to do so. Originally states were supposed to declare their intention to either set up an exchange or not by November 16, 2012. But states have been so hesitant to do so that the Department of Health and Human Services appears ready to get rid of the original hard deadline and replace it with an extended "rolling deadline." Which, as Cannon says, is not much of a deadline at all.

Individual participation levels have been similarly low. The law created special health plans for those with preexisting conditions. Enrollment in these plans was expected to reach 375,000 by the end of 2010. Instead, by the end of 2011 there were only about 50,000 people enrolled. At this point, there are only about 77,000.  

This reluctance comes despite a fair amount of administration cajoling. Not only did HHS extend the exchange creation deadline, it also beefed up the marketing budget for the preexisting condition plans in an effort to boost enrollment and redirected some of the program's funds to making the premiums lower. After an initial draft of the ACO regulations was met with great resistance, HHS published a revised and updated version designed to seem somewhat more friendly to skeptical health systems.

Yet despite the administration's repeated efforts to make ObamaCare more palatable, it's still having trouble getting third parties to buy in. Indeed, to some degree the problem extends to the public at large, which has never shown much enthusiasm for the law. ObamaCare's consistently low poll numbers tell us that despite last week's election, the public isn't buying into the president's health care law either. 

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  1. Good work Pete. Maybe Obama should try using alt-text, since he thinks his biggest failure is his inability to sell his programs to the public. Alt-text sells.

    1. I knew it was a Suderman article from the alt+text. Genius.

  2. The law encouraged the formation and operation of ACOs?large, highly coordinated health provider groups

    I took a good, hard look at the ACO regs, and I can assure you, the last thing they did was “encourage” the formation of ACOs.

    Badly drafted, grotesquely expensive, micromanaging, all-around unworkable, and guaranteed to cost you money doesn’t sound very encouraging to me.

    1. I have yet to hear anyone give a good explanation of how health care exchanges are supposed to make the system more efficient.

      1. Something, something, eliminate costs of competition, something something.

      2. Because. Understand now?

        1. That was a good “explain it like I’m five”. Now, explain it like I’m 25.

          1. Because fuck you, that’s why.

          2. Because.

            (puts gun to Auric’s head)

            Understand now?

            1. I think I’m starting to get it. Now explain it like I’m 007.

              1. “Oh, double oh seven! Your boyish charm won’t get you through this one. You simply must implement the ACO! Now get on it!”

                /Judy Dench

              2. Choose your next witticism carefully Mr. Demonocles, it may be your last.

  3. Whaddya mean “where is the Buy In?”

    My premiums and deductibles have skyrocketed the last two year. I think I’ve bought in just fine thanks.

  4. So the law will end up costing much less than anticipated because no one wants to participate?

    Silver lining?

    1. no. as we speak provider groups are working to undo the cuts in the law.

  5. “This reticence comes despite a fair amount of administration cajoling.”

    Unless you’re referring to an unwillingness to speak (and you’re not), the word you’re groping for here is “reluctance.”

    1. Yes. I too found it shallow and pedantic. Not to mention intrinsically paternalistic.


  6. I’d buy that for a dollar!

    1. I’ll pull a Prices Right and outbid you by a dollar.

      1. It is the closest without going over, ASM, get it right. It is like you don’t know The Price Is Right at all.

        1. Oh.

          I still kick ass at Cliffhanger, though.

          1. No one cares about Cliffhanger, you fool. Plinko is what the kids are into these days! No dining room group for you.

        2. I’m with you. May Johnny Olson forgive him.

          Besides, I’ll Buy that for a Dollar is nothing like The Price is Right.

          1. Hmm, I should probably rewatch Robocop since that reference went over my head.

            1. “Put down that gun, or there’ll be….trouble.”

              1. Not my fault I was born in the 90s.

  7. As of today, just 39 percent of the public approves of the law, while 47 percent oppose it.

    And yet Obama still won. What a country.

    1. It’s because 99% of the country approves of not having women dragged off to rape camps where they work for pennies and have to bear all the rape conceived children to term.

      Apparently that was a big concern this year.

      1. Ya, because that’s happening…

        I think it has more to do with 99% of the country has no idea what they’re voting for so the chose the cool, pot smoking prof over their dad’s dorky boss.

  8. The thought of MDs commenting on how medical care should be funded is ludicrous.
    Do we ask cobblers whether the government ought to fund shoe repair? MD’s are no more competent to speak to economic matters than I am to discuss surgery.

    1. Really? You don’t think they may have some insight into incentives, unintended consequences, etc? Surely what they have to say has to be assessed critically because of their self-interest, but only a fool tries to write regulations for an industry without consulting the folks in that industry.

      1. Exactly. We can definitely ask doctors how they might respond to a change in the economic circumstances surrounding their profession.

        If the government was suddenly interested in subsidizing and mandating shoe repair, we’d certainly be interested in the cobbler’s perspsective.

    2. “MD’s are no more competent to speak to economic matters than I am to discuss surgery.”

      Most MDs spend a goodly amount of their time running their business, supervising the billing, balancing the books, seeing that payrolls are met, dealing with government requirements, trying to make enough profit to feed their families. That’s a lot of very practical experience in medical economics.

  9. The law encouraged the formation and operation of ACOs

    Unfortunately, when it comes to laws and sausages, “encourage” does not translate to “conjure up.”

  10. It appears that the Obama Administration is, in fact, finding the populace “unresponsive”.

  11. So a huge and complex law written by Top Men, none of whom actually read the entire thing, turns out not to work as planned? That’s unpossible!

  12. Sometimes you jsut have to roll wit hthe punches!

  13. ObamaCare’s consistently low poll numbers tell us that despite last week’s election, the public isn’t buying into the president’s health care law either.

    I keep hearing around here that it’s unpopular with “the public”. But somehow “the public” isn’t showing it anywhere else in the known universe.

    Must be it’s a topic they only discuss while on snipe hunts. You should hear all the things I’m willing to bitch about when I’m out snipe hunting, that you won’t hear about any other time.

    If any significant fraction of the population really was hard against it, you’d think that somebody in the last election — which was not unkind to Doom-o-crats — would have wrapped their head around the fact that if the US government wasn’t entirely bankrupt already, ObamaCare has certainly finished the job.

    In a way that I sincerely doubt this country will ever recover from.

    Goddamned snipe anyway.

  14. As long as this law stays in effect it will continue to do damage. Remember the CRA was created in the Carter administration, left unfunded during the Reagan/Bush 1 years only to be resurrected by Clinton and play havoc with the mortgage market.

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