• Why Obamacare’s Troubled Rollout Might Force the Cooperation Health Reform Needs

    The following is a cross-post of my piece that appeared in The Nation earlier today.

    We’re six weeks into the implementation one of the key provisions of the Affordable Care Act, the rollout of the healthcare marketplaces. It’s been a tough month, dominated by failures of rather astonishing proportions. But sooner or later, Healthcare.gov will work, and Republican governors will grasp that bipartisan cooperation with the Obama administration is in their best interest.

    First, let’s acknowledge the failures. The most obvious occurred within the Obama administration itself, whose Department of Health and Human Services botched the launch of the online marketplace. For those of us who worked so hard over many years to secure passage of health reform, this was humiliating. We argued for years that the individual and small-group insurance market required greater transparency, along with closer regulation by competent, activist federal government.  The ACA was a strong step in that direction, but no one expected completely smooth sailing in the implementation of a vastly complex new law. Plus, the Obama administration faced implacable opposition from Republicans at both the state and the federal level. The HHS bureaucracy labored under incredible pressure due to congressional efforts to defund ACA. The Supreme Court damaged and delayed ACA’s implementation, too—first through a ponderous legal process, then through its surprising and misguided decision that effectively allowed states to refuse ACA’s Medicaid expansion. Almost everyone expected the rollout to include some embarrassing glitches. But few people expected the deep bureaucratic failure that actually occurred.

    ACA supporters draw different lessons from this experience. Technocratic centrists seek organizational strategies to make government IT management and procurement better-emulate its innovative counterparts in the private sector. Those further left note that universal social insurance is more straightforward to explain and to actually implement. These critiques do not conflict. Both have considerable validity. Both deserve greater attention in the design of future social policies.

    Last month’s performance failure hurts on a personal level, too. Many of us who fought for ACA are trying to help friends, patients, clients, and loved-ones sign up for coverage. We know many people who desperately need help, yet who remain confused or suspicious about whether they would get help under the new law. We finally had our chance to demonstrate that help was finally coming. But instead of being a moment of pride, October 1 was a moment of great confusion, embarrassment, and disappointment.

    I remain proud of ACA, proud of President Obama for securing its passage. The past month hasn’t changed that. My friends and colleagues in that effort feel the same. Yet I sense a new weariness and uncertainty. Unlike other low-points of the Obama presidency such as his loss of the first 2012 debate, the rollout of Healthcare.gov represented a substantive governance failure rather than a partisan setback. This really hurt.

    Then there was the line: “If you have insurance, you can keep it,” Obama’s promise that existing insurance policies wouldn’t change. Policy wonks always understood that this was roughly correct, but oversimplified. We failed to prepare the public for a more complicated reality, in which insurers would drop low-cost—often but not always—junk plans. Yes, most consumers are getting better plans. But some people are paying more. The President’s promise has come back to haunt him. He was right to apologize.

    The administration and its supporters made some serious errors. Yet they didn’t commit the only or the most epic failures here. News media are also making sowing public confusion. Major outlets repeatedly misreported stories of coverage cancellations within the individual and small-group marketplace. A series of stories described the predicament of specific people whose insurance was apparently cancelled, and who now apparently face massive premium increases because of health care reform. Anecdata always has the potential to mislead. Consumers with individual or small-group policies that have been cancelled are a tiny proportion of the insured, and are also a small proportion of those most affected by health reform. Many of the cancelled plans were incredibly limited, and would not have protected people from financial ruin in the event of serious injury or illness. Many people whose coverage was cancelled are eligible for subsidies on the new health insurance exchanges or are now eligible for Medicaid. Some are young adults who can enroll on a parent’s group plan.

    A striking proportion of supposed ACA horror stories fall apart entirely when subjected to scrutiny. A particularly egregious example: On October 11, Sean Hannity featured featured six ostensible victims of Obamacare. Each of the six stories proved fell apart upon straightforward fact-checking conducted by Salon’s Eric Stern. To my knowledge, Hannity has run no correction.

    Such errors are unsurprising given Hannity’s strident conservatism, but as the American Prospect’s Paul Waldman and others noted, similar examples—soon disproven—have regularly appeared in less ideologically-charged outlets. CNBC’s Maria Bartiromo called the predicament of Deborah Cavallaro, a 60-year-old California real estate agent whose insurance plan was cancelled, another Obamacare horror story. Then Los Angeles Times columnist Michael Hiltzik did something Bartiromo hadn’t bothered to do. He examined Cavallaro’s previous skimpy plan. He then poked around California’s new insurance exchange. It turns out that Cavallaro can choose several better and cheaper alternatives to her old plan.

    Consumer Reports’ Nancy Metcalf and the New Republic’s Jonathan Cohn performed a similar exercise regarding another ostensible poster-child of the evils of health reform: Florida realtor Dianne Barrette. Barrette was featured on CBS and FOX News. Blue Cross Blue Shield of Florida cancelled Barrette’s $54-a-month plan, offering to replace it with something with that costs ten times as much. That sounded bad, unless one took into account that her original policy covered virtually no services. “She’s paying $650 a year to be uninsured,” researcher Karen Pollitz told Consumer Reports. “She would have lost the house she’s sitting in if something serious had happened. I don’t know if she knows that.” Barrette can actually obtain decent insurance on Florida’s exchange at a monthly premium of about $165. When the New Republic’s Cohn went through reasonable options with her, Barrette responded, “I would jump at it. With my age, things can happen. I don’t want to have bills that could make me bankrupt. I don’t want to lose my house.”

    When Obamacare horror stories are debunked–as they repeatedly have been—the corrections generally appear in more wonky outlets with smaller audiences. Meanwhile, the anecdotes keep appearing in mainstream media outlets. These accumulate to reinforce a compelling but false fiasco narrative of health reform.

    To do better, reporters need to do two things: a) examine the consumer’s old policy to see what was actually covered, and b) compare these old policies to what is now available to the consumer through Medicaid or the new exchanges. Reporters’ failure to do these two simple things obscures a basic reality. Available coverage on state marketplaces is actually pretty good. It’s also cheaper than experts predicted when health reform was passed.

    Meanwhile, the biggest failure of health reform remains rather hidden in plain sight. More than five million low-income Americans who remain uninsured because their Republican governors refused to implement the Medicaid expansion. Because this wasn’t a surprise to anyone, this scandalous situation is getting far less attention than it deserves.

    Fortunately, there are some silver linings.

    The first reflects cyclical realities of the media. Healthcare.gov isn’t the humiliating mess it was at its launch. It will work. Eventually, reporters will notice. Ordinary Americans will, too.

    Secondly, more and more Americans will directly observe what many new Medicaid recipients and participants in state exchanges have already seen: Health reform is offering real coverage that will improve people’s lives.

    The final silver lining will be harder to accept for committed activists on both sides of health reform. Many readers might not see this as a silver lining at all. But hear me out. The Obama administration has been chastened by its poor rollout performance. It needs practical and political help from Republicans—not from Republicans in Washington, who have little incentive to collaborate, but from Republican state office-holders who have actual responsibilities to govern who will eventually own their state’s version of health reform.

    And Republicans around the country have been chastened by the Tea Party’s politically radioactive decisions to seek concessions over the debt ceiling and to shut down the government. States face powerful incentives to embrace the Medicaid expansion, which is so valuable to both consumers and providers of healthcare. In states such as Ohio, Arizona, and Pennsylvania, all of which have Republican governors, we can already see the beginnings of a bipartisan negotiation.

    Liberals like me may be disappointed by compromises the White House is likely to make to provide GOP governors with a dignified path to accept Medicaid expansion. Some states wish to impose (modest) co-pays for non-generic drugs or for emergency department use. Others ostensibly maintain the right to opt-out of the Medicaid expansion if the federal government lowers its matching rates. Republican governors require such concessions. After all, they have spent the past five years bitterly opposing health reform. Maybe HHS will follow the Arkansas compromise and allow more poor people into exchanges rather than Medicaid in states that request that option.

    The administration always seemed willing to negotiate on medical malpractice, too. This proved to be a moot point in 2009 and 2010, as Republicans preferred to trumpet this issue politically rather than to negotiate any deal. But perhaps we have another chance for movement.

    We may also be wise to revisit just how minimal the most minimal insurance packages should be. In 2011, an Institute of Medicine committee was asked to clarify what the “essential health benefits” under the new law. The IOM recommended a package based on what the typical small business would cover, and noted the importance of such restraint to keep premiums low. It was a much more limited plan than many advocates support, and the committee was sharply criticized. But this month’s backlash underscores the wisdom of the IOM’s approach. I don’t know yet what can be done without compromising public health components such as substance abuse and mental health coverage, but these matters deserve a real look.

    For liberals, these may be painful concessions. Yet this isn’t November 2008, when Democrats could plausibly look forward to imposing their legislative will. Democrats need Republican buy-in for health reform to secure public legitimacy and to help millions of needy people. Democrats also need the administrative capacity of state governments, willingly deployed, to make health reform actually work.

    Meanwhile, conservatives across the country will be equally disappointed by the compromises GOP governors must make. Some states could see more than one-third of the adult population on Medicaid. This is a huge, essentially irreversible increase in the role of government. Republicans must realize that this isn’t November 2010, when they might plausibly have overturned ACA in Congress or in the courts. That moment has passed too. Health reform is a reality. Too many individuals and constituencies are benefitting for this thing to be overturned. Meanwhile, poor people need coverage. Hospitals, city and county governments, and so many other stakeholders need federal dollars in the cash register. If Medicaid’s history in the 1960s and 1970s is any guide, Medicaid expansion will happen. Once a state opts-in, as Virginia presumably will do under governor-elect Terry McAuliffe, there’s no going back.

    The politics of enacting landmark health reform required a unique moment of Democratic dominance. The realities of implementation require something less exhilarating but more methodical. The process is messy. No will.i.am video will be made about this task, but it’s important: Cementing the change we need.

    @haroldpollack

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    • Seriously??

      ALL the problems with the ACA are someone else’s faulty?

      Is there any chance, any chance at all, that some of the problems with the ACA are the fault of the architects, rather than Congressional Republicans, Republican governors, the Constitution, the IT people…..?

      Was this really that rare example of a perfect accomplishment of human endeavor, merely dragged down by the mendacity and incompetence of others?

      Let’s set aside the ability of the federal government to launch a major new benefit program and website.

      Can a supporter at least concede an error in designing a system that would only work if

      i. the Democrats maintained control of both houses of Congress in perpetuity,

      ii. the Democrats captured all the governorships,

      and

      iii. We repealed the Constitution?

      Did these really seem like good ideas?

      • @DBH

        If the VA, Medicaid, Medicare, and EMTALA, are all constitutional (not to mention the ACA, according to SCOTUS) please inform us of exactly what is wrecking the constitution.

        Enquiring minds want to know.

      • see, you’re trolling again

      • In a sense, one might argue that some of the ACA problems are the fault of Congressional Republicans. Due to the 60 vote cloture requirement in the Senate, and due to the Republican majority in the House after the 2010 elections, repairing/improving the ACA has become impossible. For the time being, the choice is between continuing the convoluted and flawed law as it — which the Republicans cannot prevent — or essentially repealing the law altogether — which the Democrats will not allow.

        In my opinion, the ACA was and is the worst possible health care system … except for the status quo ante all the other systems that could have passed through Congress in 2010 or since.

    • I am continually dismayed at the focus on Medicaid as a solution to healthcare needs. Republican governors are resistant to expanding it because of a budgetary concern, which is the least of Medicaid’s problems. This program is almost worse than no coverage at all. You think you will be able to see a doctor and have your visit covered, yet almost no doctors will take you as a patient; the one that does will schedule you 6 months out, which is the first open appointment. The more people Obamacare leads into Medicaid, the worse this problem will become. The government can sign up as many people as it wants into the program, but it cannot make enough doctors to cover the treatment. Isn’t the false hope that “now I will have coverage” cruel?

      If you really want to suggest compromise that will truly help people receive coverage that will work, stop looking to the expansion of Medicaid as the answer. A government-funded HSA for routine preventive care along with a catastrophic would give someone a better chance at securing a doctor. Also, it would give the person dignity. Calling around to find a doctor who will deign to take your Medicaid is humiliating. I believe that champions for Medicaid have not actually used the program themselves. If they have, I don’t see how they can continue to advocate for it. We can do better.

    • “Is there any chance, any chance at all, that some of the problems with the ACA are the fault of the architects, rather than Congressional Republicans, Republican governors, the Constitution, the IT people…..?”

      How can you, as a card-carry conservative, even ask that?

      Of course the ACA’s basic structure is perfectly sound and the vast majority its problems are someone else’s fault. Said basic structure was designed by a right-wing think tank as a way to prevent us bleeding-heart liberals from taking health insurance away from the insurance industry. And it was tested and found to work just fine, in Massachusetts.

      So your whole rant is hypocritical in the extreme.

      Let me reiterate: we accepted this complex right-wing-designed kludge* because the right wing screamed for it. We’d much prefer single-payer with Japanese-style restrictions on charges. But you guys were so terrified of true health-care system reform, that you designed and demonstrated an alternative. You guys busted your butts to save the insurance industry, doctor’s sky-high incomes, and hospitals’ and other providers’ profits.

      (Moderator: please accept this note. I know it’s not nice to call someone hypocritical, but dbh’s argument really is exactly that, and he needs to be told so.)

      *: Truth in advertising: I don’t think it’s all that much of a kludge. Getting a health care system right is going to involve a lot of fine print, and that will include defining what “health care coverage” means; which is much of the ACA’s work. I’m actually quite impressed that it makes sense at all.

      • dbh, Your remarks were entirely on target despite the fact that the Heritage foundation made a terrible mistake that they later admitted and apologized for. However, that idea was meant for a single state to experiment with and not to the entire nation. Massachusetts is still an open experiment and has many problems. I find DL’s comments quite inaccurate.

      • That was some of the most unconvincing, unintellectual, biased drivel I have read in a few days, and that is quite the accomplishment. Not one single Republican voted for that travesty. Pointing to Romney is the new Pointing at Bush. It’s all fun and games until it costs you seats in 2014. This thing is yours and your alone. If you all want to sing yourselves to sleep, convinced that these epic failures will force the other side to play ball, you are delusional. You will lose this game and I will very much enjoy watching it happen. You love command and control economies, but you know nothing about economies, flow of capital or people.

        • Would you describe what you imagine it will look like when “they” lose this game and what part you will most enjoy watching happen?

      • Sorry – but I just can’t let this go unchallenged.

        1. The meme that the ACA is the same as what Heritage proposed is reeeeallly getting old and frustrating. Heritage on their site summarizes the very significant differences. AND – the Heritage plan never got off the ground – the individual mandate was and still is troubling to those of us who value personal choice and liberty.
        2. The “deals” to support the ACA were made by the Dems – not “you guys”. The administration did not want the updated version of “Harry and Louise” on TV screens so it made deals with insurance, companys, the AMA, drug companies, AARP and even bribed a few Senators to barely push the bill across the finish line.
        3. Despite attempts to deflect blame – this mess – and it is a mess is the responsibility of progressives. As someone once said “you break it you own it” – and it is badly broken.

        Personally, I have come around to believing that the best thing to do is to try and fix this mess. But fixing it is going to take some leadership from the President. He is going to have to swallow his pride and make the first move. Some of the things conservatives might respond to…

        1. A loosening of the essential benefits scope. Allowing plans that do not require coverage of maternity, birth control, substance abuse and first dollar coverage of basic sevics to be offered along with comprehensive plans.
        2. A fix to the 30 hour problem – this might or might not be as simple as raising the threshold to 40 hours.
        3. Expanding the availability of catastrophic plans – and coupling this with HSAs- and allowing at least a partial rollover of unused HSA balances.
        4. Adding a portion of the Federal workforce to the risk pools of the exchanges. This would have both symbolic value, but might make the pools more attractive to insurers.
        5. Lowering the trigger points for Cadillac plans – not all of my Conservative friends will like this – but some way to raise more revenue needs to be found – and fast. This might be the best/only source

    • My favorite James Carville quote is, “When your opponent is
      drowning, throw the son of a bitch an anvil.” I think that the ice
      is melting underneath the feet of those who supported the ACA in
      the Congress and the legislatures. Many will soon be in the water
      and the anvil will fall next. I don’t know Prof. Pollack feels that
      the Governors and Legislatures in the 35 states who chose not to
      participate in the ACA exchanges or the 25 states who refused the
      medicaid expansion would feel any pressure to step forward and
      agree to any terms offered by the Executive Branch. Quite the
      contrary, they will accept nothing less than to dictate the terms.
      Some states like Texas have Republicans governing with 65 percent
      majorities. The refusal to participate in the exchanges and expand
      medicaid is extremely popular in Texas and in many of the other
      states as well.

      • ” I think that the ice is melting underneath the feet of those who supported the ACA in the Congress and the legislatures.”

        Did you also think the polls were skewed last year and Mitt had mentum?

        “Quite the contrary, they will accept nothing less than to dictate the terms.”

        Right wingers have stated this since the day Obama was elected. Their entire philosophy is to take an elections be darned approach and act as though they have control of both houses and the WH.

        Unfortunately, polls have consistently shown their “Give me everything I want and then some or else!” Approach is costing them elections, and they see just how abysmal their approval ratings are as a result. The few with functioning brain cells are finally getting that they need to start making compromises.

      • I’ll have to bookmark this comment of J’s just so I can return to it four years from now when it’s obvious to all that the places that didn’t sabotage Medicare expansion and the ACA rollout are doing really well and the places that did are suffering.

        I will also enjoy seeing the effects of this combined with accelerating demographic changes that will in a few years overwhelm even Texas’ extreme gerrymandering and high-tech Jim Crow “voter ID” voter suppression laws.

        • “I’ll have to bookmark this comment of J’s just so I can return to it four years from now when it’s obvious to all that the places that didn’t sabotage Medicare expansion and the ACA rollout are doing really well and the places that did are suffering.”

          I think you intended to say “Medicaid expansion.”

          However, if you believe the problem with ACA is a lousy rollout or software engineering problems, you are not grasping either the scope or the devastating nature of the problem.

          Those of us who have opposed this legislation since its inception are not surprised by this outcome, however, few of us had any idea it would fail so quickly and completely. We are actually facing a situation where it is likely that five to ten million FEWER people will be insured on January 1 than were on October 1.

          This is not a laughing matter. Some of these people are going to need health care on January 2, and are going need chemo and other expensive treatments and they will not have insurance.

          If you think the problem will be solved by getting the website up and running, you’re not understanding the problem. People are not going to buy insurance through the exchange because it is more expensive for most people. And the young people who wouldn’t pay $100/month for insurance last year aren’t going to pay $200/month next year. That’s a ridiculous pipe dream.

          This is a disaster. And it doesn’t need to be fixed. It needs to be thrown out, repealed, and replaced with a market-based solution (after all, the markets in health care functioned just fine until July, 1965).

        • “However, if you” Phoenix Woman “believe the problem with ACA is a lousy rollout or software engineering problems, you are not grasping either the scope or the devastating nature of the problem.”

          Phoenix Woman, there are many historical examples of what happens when the left takes control for an extended period of time. Compare Detroit (run by guess who) formerly one of the greatest cities. Compare that with Texas. You can do that over and over again.

          StackPointer is entirely right especially with regard to those that are presently sick and receiving complex treatments. Since the exchanges cut the panels of doctors many of these people will be very negatively impacted. Sophisticated treatments frequently rely upon large panels.

    • “Some states could see more than one-third of the adult population on Medicaid. This is a huge, essentially irreversible increase in the role of government. ”

      If true, it will have a dramatic impact on our economy – a massive burden on working Americans who secure their coverage through their employer-sponsored plan. Today, three public program costs financed by workers often reduce take home pay by more (on average, and averages can be deceiving) than the worker’s contribution for their own coverage:
      (1) For Medicare Part A,
      (2) For Medicare Parts B & D,
      (3) For Medicaid at current enrollment levels.

      To those four burdens, we will now add a fifth burden – to expand Medicaid to up to 1/3 of low-income adults without dependent children or not disabled, and a sixth burden, to subsidize public exchange coverage for those with incomes of up to 400% of the Federal Poverty Level (up to $94,000 for a family of four) for those who do not have access to qualifying, employer-sponsored coverage. Bottom line, these expansions are not free, but are ultimately going to be shouldered by taxpayers, generally, those same working Americans. Or, perhaps the design has always intended to shift as much of the cost to expand coverage today by adding to the deficit and public debt, so as to send the bill to America’s children and grandchildren.

      And, we are going to do this at a time when:
      – The civilian workforce is at a 40 year low as a percentage of the adult population – it declined by 720,000 (10/13), and the labor force participation rate fell by 0.4% to 62.8%; and
      – The percentage of non-elderly Americans with employer-sponsored coverage continues to decline – despite the delay in the employer mandate.

      Really, you still believe this is the right law, at the right time, with the right design, and at the right price?

      • You pay for these uninsureds now. Repeat: in your premiums and assorted medical care costs you pay for the uninsured now. And that will continue until you change the law that mandates treatment in the ER be denied to those who cannot pay and/or have no insurance; plus you change the bankruptcy laws to make any medically incurred expenses be non-dischargeable. Of course in doing so you will have one: forced people to die at the ER door and/or suffer horribly. Two, you will create debtors for life who can never improve their lives as their debt is crushing.

        Are you willing to do that?

        Moreover, are you willing to give up the tax exemption for your employer based health plan? You don’t hear much about the uninsured complaining about your tax break do you? A tax break that is by far the singles biggest drain on the US Treasury. Funny how that is isn’t it?

        The better question is why insist on sticking with a system that is the most expensive in the world and doesn’t even deliver great results? Why? Remember, the rich will ALWAYS have access to the best medical care in the world; what we need to do is make a program that works for all of us.

      • I think few of us who strongly support the ACA think this is the right law at the right time for the right price. In the end, the ACA is a minor fidget to a kludge of a system with 3 forms of Gov’t healthcare (Medicaid, Medicare and the VA), tax subsidies for employer health insurance, gouging of the un or under-insured, and a minuscule individual market.

        However, since the GOP is so obstructive, those of us who would really like a real reform are stuck supporting the ACA on the grounds that it’s a step towards reform and any reform is better than getting further entrenched in the really stupid system we have.

    • “It needs practical and political help from Republicans—not from Republicans in Washington, who have little incentive to collaborate, but from Republican state office-holders who have actual responsibilities to govern who will eventually own their state’s version of health reform.”

      No we see the real problem.

      Democracy.

      The Republicans in Washington have no incentive to cooperate because they are responding to their constituents. This is the same for Republicans at the state level.The Republicans in Congress, like the Republicans holding state office, are elected by voters in their states. We are not going to get to the nirvana of federal control of the entire economy while these voters keep electing Republicans.

      We have to prevent these voters from voting for people who will pursue the “wrong” policies.

    • SAO,

      Re: That pesky Constitution. SCOTUS found that the mandatory expansion of Medicaid was unconstitutional. Of course, the perfection that is the ACA defined not only a maximum income to be eligible for subsidies, but also a MINIMUM income. Below that people cannot receive subsidies. But without mandatory Medicaid expansion, we now have people who are simultaneously too rich to qualify for Medicaid and too POOR for subsidies.

      Perfection, indeed.

      Littleboy,

      I think I follow most of your argument, but I get lost right at the end.
      As I understand it from you
      1. The ACA is perfect
      2. Republicans wrote the ACA
      3. Republicans engineered enactment of the ACA by forcing the Democrats in Congress to pass it. How did they make the Democrats do this? By unanimously voting against it! Brilliant.

      So, if you support the ACA, you should thank the Republicans. The Democrats had nothing to do with it except to dance when the Republicans pulled the strings.

      The one thing I don’t get. If you like the ACA, you think it is perfect, and you think it was written and passed by the Republicans, why are you unhappy with them?

      elboku,

      Tax exemption for employer based health insurance “by far the singles biggest drain on the US Treasury. “???

      Not even close. Medicare and Medicaid are each bigger than the tax impact of the tax exemption on employer plans. The combined state and federal impact is less than the budget of HHS, less than the budget of the Social Security Administration, less than the budget of the Department of Defense, less than the budget of the Treasury Department.
      Not. Even, Close.

      ” are you willing to give up the tax exemption for your employer based health plan?”

      No.

      I am not willing to do anything that increases the revenue of the federal government. The ACA rollout is actually going considerably better than one would have expected. I suspect there are really many more problems, not yet reported, that would put this mess about where one would think a new massive federal program would be.

    • Since zero republicans voted for Obamacare, and republicans had zero input in implementing it, I find it laughable that you would assign so much blame to republicans for its obvious failures.

      I don’t know if you really believe what you write, or if you’re simply trolling. Either way, it’s not impressive.

    • Harold,

      Re: “If you have insurance, you can keep it.”

      If “Policy wonks always understood that this was roughly correct, but oversimplified,” why didn’t policy wonks, including the very cable policy wonks at TIE, warn President Obama to cool it?

      I hesitate to call the promise a lie, but in hindsight it seems to me to have been knowingly deceptive. Did policy wonks regard the promise as a “white lie,” where the ends justified the means? I believe the President is not the only one who needs to apologize; policy wonks need to line up too.

      I support the ACA. (I regard it as convoluted and flawed but the best we could do at the time.) If the ACA falls (is repealed or vitiated), however, it will not be due to its inherent flaws but due to unforced errors in its promotion and implementation: the promise, the web site, and the President’s remarkably poor salesmanship.

      I am afraid these errors may enable the Republicans not only to retain control of the House but also to gain the majority in the Senate. Then only two things will prevent repeal of the ACA: the filibuster in the Senate and the President’s veto power. Then the ACA becomes a (if not the) central issue in the 2016 Congressional and Presidential elections. With sufficient demagoguery, the issue could turn the swing states Republican, producing a Republican President and a larger majority in the Senate. Then two or three frightened Democrat senators decline to support a filibuster, and repeal passes the Congress and is signed by the Republican President.

      Only one thing will prevent the nightmare: effective implementation of the ACA before the 2014 elections.