Friday, October 11, 2013

Failed Technology, not Congress, Is the Biggest Threat to Obamacare

Remember when House Republicans were insisting that they would not agree to re-open the federal government unless Obamacare was defunded or delayed?  Well, that was then, this is now.  Ten days into a partial government shutdown that was caused by the GOP-controlled House passing a funding extension that also delayed Obamacare, and just a week from when the Treasury Department says that the debt ceiling will be breached, the GOP leadership seemingly has dropped changes in Obamacare from its list of demands.

 Instead, as Roll Call’s David Hawkin’s notes, House Budget Chairman Paul D. Ryan has, “come out with a roster of proposals on which he thinks both sides can come to agreement — and none of them has anything to do with limiting or altering Obamacare.”   Politico reports that, “The emerging House GOP plan would come with some conditions, although not the kind of sweeping demands to defund or repeal Obamacare. Republicans would vote to lift the debt ceiling until Nov. 22 — just before Thanksgiving — while prohibiting the Treasury Department from using extraordinary measures to lift the borrowing limit.  Boehner said Republicans would also demand a formal House-Senate conference on larger budget issues, a process Senate Republicans have been blocking since their Democratic counterparts approved a budget resolution earlier this year.”

 It remains unclear if the House leadership would be able to get restive Tea Party conservatives behind such a temporary increase in the debt ceiling without requiring other cuts and/or changes in the Affordable Care Act, or whether President Obama and Senate Democrats will agree to it.  And a temporary increase in the debt ceiling would not end the government shutdown itself—the House, Senate, and White House would still need to come up with a bill to restore funding to federal agencies, and Senate Majority Leader Harry Reid (D-NV) reaffirmed today that the Senate will not negotiate with Republicans until they re-open the government. But a temporary debt ceiling would (for now) avert the economic calamity that would occur if the U.S. Treasury can no longer borrow money after October 17.  

So it is looking now like the GOP fight to use the debt ceiling and the shutdown as leverage to delay Obamacare will end not with a bang, but a whimper, paraphrasing T.S. Elliot.   That the GOP lost the fight to defund or delay Obamacare was entirely predictable: they never had the votes.  As John McCain told CNN’s Wolf Blitzer last night, “We started this on a fool’s errand, convincing so many millions of Americans and our supporters that we could defund Obamacare…[That] obviously wouldn’t happen until we had 67 Republican senators to override a presidential veto.”

So Obamacare will survive the current effort to kill it in Congress, just as it survived the Supreme Court and two elections.  Now, Obamacare’s biggest obstacle may be itself: the technical infrastructure that has performed so poorly in its first ten days that millions of people have been frustrated in their efforts to access information through the government’s enrollment website,  The New York Times reported that, “The technical problems that have hampered enrollment in the online health insurance exchanges resulted from the failure of a major software component, designed by private contractors, that crashed under the weight of millions of users last week. ”  Time magazine reports that if the problems persist into November, then, “the health law’s future could be imperiled, according to a former high-ranking health care official … ‘By November—certainly the middle of November—the sites have to be able to handle major traffic for people to be able to set up accounts and purchase coverage,’ says Joel Ario, who served as director of the Office of Health Insurance Exchanges at the U.S. Department of Health & Human Services (HHS) from August 2010 to September 2011. ” 

So the biggest threat to Obamacare is not the Republicans in Congress, or even the  Republicans in states that are resisting it—it is the administration’s own failure so far to fix what Time rightly calls “crippling computer glitches” that are frustrating the people who are trying to buy coverage.  The administration says that things are getting better day by day, as it has increased server capacity and fixed other “bugs” in the system.  Maybe they are, and I certainly hope so.   But until they can show that the system is working reliably and consistently, the Affordable Care Act is at risk, and for this, the administration has no one to blame but itself.

Today’s questions: What do you think of congressional Republicans apparently giving up on their efforts to defund or delay the Affordable Care Act?  And of the technical problems plaguing Obamacare enrollment?


ryanjo said...

Wow, 4 consecutive columns about the trials and tribulations of Obamacare. Feeling defensive?

The issues in Congress are much bigger than Obamacare. There is a loss of middle ground between the two sides, and the debt ceiling and Obamacare are just convenient rallying points for each party. Some of us (less politically savvy no doubt) look at the past, recent and future shenanigans of our political leaders, and wonder whether they are the best to guide delivery of healthcare.

Case in point: the miserable failure of the signup process for Obamacare so far. Oh, it's technology that failed? No, it was the typical inadequate planning, implementation and management that characterizes government programs. Well, at least the average citizen can experience what physicians offices face every day.

Robert J. Sobel, M.D. said...

Dear Bob:

Long time just in reading mode. Got lots of HIPAA compliance and EHR transition issues to fill in the space. Patient care still where all the time is spent.

The reality of the current insurance marketplace is being altered incrementally by the changes contained within the ACA. Whether privacy concerns can be written off remains a legitimate question in this early phase. It does represent an opportunity for many, and successful access to fair insurance policies does seem preferential to expanding Medicaid.

Whether the private market can stabilize will depend upon how effective the various rules are in further isolating private practice. That bipartisan riff on perverse incentives in "fee-for-service" remains a driving force in your accelerating bureaucracy projects (ACO's, medical homes). I cannot condone this trend. Indeed, I feel it is much more dangerous than the fostering of a private insurance individual market modeled on fee-for-service.

So let's be optimistic and look at the possibility of a debt limit vote, a re-opening of the government, and a real adjustment of our entitlement fiasco.

Our liberal natures support a safety net, but we have created an impossible financing reality with our current Medicare/Social Security ratio vis a vis the rest of us. The Republicans are right to force this discussion, and the options were already set forth in the previous debt commission report.

For healthcare, I stand by my long-standing sense that the urgency is in fixing the pricing of the new. This must be done while fostering more balanced incentives in innovation (not the drug life cycle manipulation that Hatch-Waxman has engendered). A brand-only, single-standard, less redundant, price-regulated, pharmacy benefit/third party hassle free, regulated royalties system would be a true advance. IT WOULD BE A MUCH BETTER MODEL FOR REGULATION OF INJECTABLES AND COMPOUNDING PHARMACIES AND BIOSIMILARS THAN HATCH-WAXMAN IS. Instead, we are compromising the independence of the medical profession with the dictates of an over-developed federal bureaucracy. I can accept price regulation a lot better than quality measures and meaningful use bonuses. Apply it to the health care commodities, and let professionalism take care of the rest.

Health care is local. States are the primary regulators. Whether the unfettered United Health Care Undercut/Marketing Model or the state-constrained but repeatedly successful Blue Cross monopolization model, setting some basic rules at state levels (with a modicum of federal standardization) could serve as a restraining force on their excesses. If new drugs and procedures didn't draw their exaggerated mark-up, there would be less need to persuade (drug-reps) or dissuade (prior approval hassles) physicians. This evolution in the current reality we must face would serve well our quality of life. It would also foster a more clear picture of how new approaches compare with old ones. Most importantly, it would stabilize health care costs without the overt rationing in the offing.

ryanjo said...

There is now more evidence that the present "bugs" in the software (as the Administration calls them) were evident as long ago as March 2013, and represent major structural flaws in the signup process: "Confidential progress reports from the Health and Human Services Department show that senior officials repeatedly expressed doubts that the computer systems for the federal exchange would be ready on time, blaming delayed regulations, a lack of resources and other factors." (New York Times, 10/12/13,

Saner minds would have opted for a pilot expansion of eligibility and a gradual rollout. More ammunition for ACA critics? Sadly the President, only interested in his legacy, remains in denial.