• A brief note on ACA implementation hurdles and delays

    Maybe I’m observing a skewed slice of the media, but it seems like many are blaming ACA implementation issues and delays on the Obama Administration or inherent flaws in the law itself. Is that fair? Maybe. Is it the whole story? Hardly.

    Harold already noted that the Supreme Court’s decision to make the Medicaid expansion a state option threw in a monkey wrench, and few saw it coming. He also mentioned the limited resources that Congress has made available for implementation and the political gridlock on the issue that prevents sensible adjustments.

    It should, however, also be said that states have a huge role to play in facilitating or interrupting the implementation glide path. For reasons I find completely reasonable — though still risky — many officials delayed putting full weight behind implementation until after the the Supreme Court passed judgement and the 2012 elections were decided. Some have put their full weight behind impeding implementation, which is their right. However, the active opposition to implementation is not a design flaw or the Administration’s doing. (I’m passing no judgement on it here. Just pointing out the obvious.)

    There shouldn’t be much dispute about this. David Jones and Scott Greer wrote the same thing in a recent paper in the American Journal of Public Health.

    Many Republican governors and legislative leaders delayed making decisions until after the Supreme Court upheld the constitutionality of the ACA and President Obama won reelection. […]

    [One] view is that Republicans will continue attempts to undo the law by remaining uncooperative. Because the ACA is so closely associated with President Obama and Democrats, many Republicans see little to gain politically by supporting their state’s exchange, but much to be gained by helping it fail. […]

    However, even if these governors are willing to support implementing components of the ACA, they could be blocked by coalitions of legislators whose incentive is to appeal to the preferences in their districts rather than in the entire state. For example, the Republican-controlled Michigan Senate was able to prevent the creation of a partnership exchange despite support from Governor Rick Snyder (a Republican) and approval from the Department of Health and Human Services, by not allowing state agencies to spend federal grants they had received.

    Their whole paper is worth a read. It’s brief and, I think, ungated.

    Implementation is a long, hard road. To be sure, it’s made harder by the nature of some aspects of the law itself. I have little doubt the Administration has made some errors in planning, which should be expected of any human endeavor. But it’s also clear that there are other forces at work.


    • Doesn’t appear to be engaged.

    • Sorry, you or almost any one of your highly intelligent readers could have drafted a proposed regulation to implement the required data reporting to implement IRC 6055 and 6056. The regulation could have been finalized way back in 2010 under the Administrative Procedures Act. That was the asserted reason for the newest delay in implementation regarding the employer shared responsibility penalty taxes. The regulation was not dependent in any way on any other feature of PPACA, and therefore, it could have been proposed, updated, adjusted and finalized concurrent with all other PPACA activity.

      Employers could have easily had payroll/HRIS systems in place, tested and ready to go, more than two years ago – and the payroll/HRIS vendors would have gladly embraced the added revenue from making those changes.

      So, this delay has absolutely nothing to do with Medicaid, Supreme Court, Republican Governors or even the ability of the agencies in the Obama Administration.

      None of us know the reason for delay, and those that do, put out this lame excuse.

    • ” I have little doubt the Administration has made some errors in planning, which should be expected of any human endeavor.”

      The nature and magnitude of the errors in a given human endeavor is predictably dependent on the magnitude and complexity of the plans and the extent to which we understand the system that the plans are being imposed upon.

      This is a massive planning enterprise being imposed on an immensely complex system that we don’t understand very well. Errors in planning would be a given even if a) everyone thought that the ACA was a perfect policy initiative and b) undertook heroic measures to implement it.

      Failure to appreciate that neither a) nor b) would be satisfied in any conceivable model of reality is but one of the administration’s failure’s to plan, and not the most significant. That status is reserved for the hubris involved in choosing to opt for this route instead of more limited, but tractable plans that were much more modest in their ambitions and smaller in their scope.

      • Indeed. There are many simpler ways to cover a greater proportion of the uninsured than Obamacare likely will. Some of them don’t even rely on state cooperation. I bet you can think of some. However, I can think of none that would have passed. Perhaps the fundamental flaw is even striving to expand coverage. Be that as it may, many do hold that as a goal.

        OTOH, even imperfectly, Obamacare will substantially expand coverage. The potential for a larger expansion is built in, provided states want it. And *if* that is one’s goal, one might be satisfied. Not saying *you* or *I* should be though.