• JAMA Forum: The politics of ACA doom and gloom, a self-fulfilling prophesy

    What does ACA implementation have in common with that of Medicare Part D? And how does that relate to a potentially self-fulfilling prophesy of doom and gloom? Wouldn’t you like to know? Well, just click over to my JAMA Forum post and find out!


    • You may have a point about the popularity of an insurance program, and the popularity of the President in that particular region, supporting the program.
      Politics and popularity aside, Part D was an immensely expensive commitment. With no pre-funding, the government pays 75% of the premiums, increasing the deficit, and the debt held by the public. Only 25% of the premiums are paid by the beneficiaries. Why shouldn’t it be popular?
      And, there are “economists” out there who support the “trust fund perspective,” (a term which implies there are enough people who believe this nonsense to actually have a term for this group thinking) , claiming Part D to be fully paid for, for perpetuity!
      Don Levit

    • I posted this same comment two days ago in response to Aaron Carrol’s comments about the most recent delay, which he, and apparently you believe has something to do with resistance to PPACA.

      Sorry, but no. 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. 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. It was this data challenge that the Administration asserted was the reason for the newest delay in implementation regarding the employer shared responsibility penalty taxes.

      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 and creating those data files. Just another data element, a law cost of coverage reporting on the W-2.

      So, this delay has absolutely nothing to do with Medicaid expansion, the Supreme Court, the 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.

    • My point is that you focus on the level of support by state officials where that has nothing to do many of the delays and challenges in implementation – particularly the most recent announcement. How convenient and timely your post, that would levy criticism not where it belongs, on the agencies and the law itself, but only on those states that did not embrace PPACA.

      how did state officials in those states that resisted PPACA create the most recent delay in the employer mandate?

      • I was relating the ACA rollout to Part D, which I have studied. I don’t see a reason to expect a different experience. In states where officials are less supportive, I expect participation to be relatively less vigorous. I understand you have a bone to pick. It’s a perfectly fine bone. Pick away. But it has nothing to do with my post.

    • OK, just seemed like it was a convenient excuse to blame delays and implementation issues on others where that is clearly not the issue – at least not with respect to the most recent delay.

      At the same time, not sure how you can compare state support for Medicare Part D to state support for PPACA – given the dramatically different levels of involvement in the rollout efforts. If you are suggesting that it was a mistake to give states a role in PPACA implementation, perhaps they should have eliminated Medicaid as we know it in favor of a more Medicare-like program.

      I have not studied the Medicare Part D rollout. But I do remember that they targeted the 4th quarter 2005 as the enrollment, but failed miserably and extended enrollment through May 2006. PPACA is already scheduled to extend enrollment through March 31, 2014, and I would not be surprised to see that effective date slip as well.
      However, as best as I can recall, the states had almost no involvement with the creation of PDP’s and expansion/adjustment of Medicare Advantage options (nor the enrollment process) – the top two elements and implementation challenges from the Medicare Modernization Act of 2003 for the ~44MM Medicare-eligible Americans at that time. The one issue that was a struggle, if I recall, was the dual eligibles – where significant outreach was necessary.

      At that time, I was in the plan sponsor role for a Fortune 100 employer with retiree medical coverage. We considered the options and instead of claiming the retiree drug subsidy, we changed our retiree Rx coverage to create one of the first Employer Group Waiver Plans. The only challenge we faced in that action was the lack of insurers/vendors who were willing to create a EGWP – now the preferred retiree Rx option among many of the few employers who still offer retiree medical.

      At least for plan sponsors subject to ERISA and the tax code, there was and is no comparison of the rollout of Medicare Part D and the mess that is PPACA.