It Could Have Worked

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The Brookings Institution’s Elaine C. Kamarck and Sheila P. Burke have published a research paper on the implementation of the Affordable Care Act. It’s classic Brookings: judicious, competent, useful. The piece contains an overview of which states are where in terms of expanding Medicaid and establishing health care exchanges. As a rule, Republican-led states are nowhere.

The authors propose to look beyond the, umh, difficulties with the roll-out of the exchanges. Those short-term, start-up kinks, they suggest, we’ll work out over time. I’m not so sure. As the authors note, we have never tried anything of this complexity, least of all in such a highly charged political environment. And I can think of programs that have remained decidedly kinky for years on end. The Earned Income Tax Credit and Medicaid are both on point (as the lawyers would say), and both are notoriously fraud-ridden and wasteful. They “work” only in the sense that we have chosen to ignore the problems and are unwilling to do what it would take to fix them (routine audits for EITC claimants, for example).

The ACA is already moving on that trajectory. Thus (the authors report), the IRS isn’t going to check subsidy claimants’ income information, or whether folks who say they have obtained health insurance coverage have in fact done so. (If they haven’t, they’d have to pay the tax or penalty or whatever.) Wringing the errors and fraud out of the system would require draconian measures, which we aren’t going to take. But never mind; it’s all for a good cause.

Many of the ACA’s long-term problems, Kamarck and Burke write, will be caused or exacerbated by the pesky “red” states’ failure to cooperate. For an assessment of how the ACA was supposed to work—reductions in the number of uninsureds, lower premium costs, and the like—we’ll have to look at the “blue” states, with exchanges of their own and an expanded Medicaid system. The authors flag (although they don’t share) a line of argument that will soon become a drumbeat: the ACA could have worked if politics hadn’t interfered. Of course HHS can’t run exchanges in two dozen states; it was never meant to. Of course there are more uninsured folks: the evil Supreme Court allowed states to opt out of the Medicaid expansion. Etc.

What kind of a mindset is that? This:

I would have loved nothing better than to simply come up with some very elegant, academically approved approach to health care, and didn’t have any kinds of legislative fingerprints on it, and just go ahead and have that passed. But that’s not how it works in our democracy.

That’s our President speaking, as quoted by George Will in his Sunday column. If only we could hand government over to some economist at MIT, it would work.

No, Mr. President: it wouldn’t—not if your objective is to re-engineer life on this planet. What we have here is a myth in the making, and we will hear an awful lot of it.