Sorry liberals, Obamacare’s problems go much deeper than the Web site
By Ezra Klein, Published: October 25 at 11:40 am
There's been a rash of commentary from some on the left who've decided that the real problem with Obamacare isn't the crippling technological issues that have made it impossible for almost anyone to enroll in the federally run health-insurance exchanges but the media's coverage of those problems.
It's not the crime, it's the lack of a cover-up.
The complaint takes different forms. Salon's Joan Walsh frames it instrumentally. The coverage, she writes, "only aids [the] unhinged right." In this telling, the problem with reporting on Obamacare's problems is that it helps Obamacare's enemies.
Zerlina Maxwell frames it as a question of insured journalists being unable to see past their own rarified position. "The privilege of analyzing the process from the perspective of someone who is already insured and not in need of coverage allows the core impact of the new program on the health and security of millions of Americans to be missed," she writes.
There are dimensions to these arguments that really center on the job of the journalist, and there, I think Walsh and Maxwell and I simply disagree. But behind this disagreement is a question about how deep the law's problems really go. As Walsh and Maxwell (and President Obama) say, Obamacare is more than just a Web site. More balanced coverage, they believe, would be emphasizing all its other good qualities.
"I was actually happy to see the president come out defiantly in his Rose Garden talk, describing the ACA as 'not just a website' and listing the many benefits it’s already providing," wrote Walsh.
"Obamacare is more than a website," repeats Maxwell.
Obamacare's problems go far beyond its Web site.
A failure in the press coverage of the health-care exchange's rocky launch has been in allowing people to believe that the problem is a glitchy Web site. This is a failure of language: "The Web site" has become a confusing stand-in phrase for any problem relating to the law's underlying infrastructure. No one has a very good word to describe everything that infrastructure encompasses.
In brick-and-mortar terms, it's the road that leads to the store, the store itself, the payment systems between the store and the government and the manufacturers, the computer system the manufacturers use to fill the orders, the trucks that carry the the product back to the store, the loading dock where the customers pick up the products, and so on.
It's the problems in that infrastructure -- indeed, much more than "just a Web site" -- that pose such deep problems for the law.
As Sarah Kliff and I wrote in our overview of the health-care launch's technical issues, the challenges right now can be grouped into three broad categories: problems with the consumer experience on the HealthCare.gov Web site, problems with the eligibility system, and problems with the hand-off to insurers.
The problems with the Web site are the difficulties consumers are facing when they try to log on and shop for insurance coverage. These problems -- error messages, site timeouts, difficulty logging in to an account -- make it hard for an individual to buy coverage through the marketplace. They are the reason why some people have made upward of 20 attempts at purchasing a plan. These are the problems that are being fixed fastest and that are the least serious.
The eligibility problems strike when consumers send in their information and the government's computer systems tell them whether they're eligible for Medicaid, health insurance subsidies or nothing at all. The system is returning incorrect data for many applicants -- meaning they might be eligible for Medicaid and not know it, or they might think they have subsidies that will later be revoked.
The insurance problems are seen by the insurance companies. Health plans are supposed to get a report when someone uses HealthCare.gov to buy their health insurance policy. Those reports are full of inaccurate data, such as the wrong address, or are being sent in duplicate. (One insurance company reported getting one of these reports, known as an “834 transmission,” that said one individual had three spouses. This person was not, for the record, a polygamist.) And it's not just private insurers: The federal system is also failing to sign people up for Medicaid.
No one quite knows the extent of the problems in each of these areas. No one knows how long it will be until all these systems are working tolerably well. No one has any idea how long it'll be until they're working smoothly. And if that was all this was -- a multi-month delay and a lot of frustration and problems for people trying to sign up for health care -- that would be bad enough. That would be a story worth covering aggressively and constantly until the problems cleared up.
Maxwell speaks of privilege, but one privilege the insured and well-off have is to excuse the terrible quality of services the government routinely delivers to the poor. Too often, the press ignores -- or simply never knows -- the pain and trouble of interfacing with government bureaucracies that the poor struggle with daily. That can allow the problems in those bureaucracies to fester.
Maxwell and Walsh seem to think there's something false about members of the press trying to run through HealthCare.gov and the call center themselves. But this is actually a profound benefit of Obamacare's digital architecture: The fact that member of the press can learn how unworkable the site is and see that the call center often drops your call or leaves you with staffers who can't help makes it likelier that the government will be under continuous pressure to elevate the level of service.
But that's not all this is. Indeed, if the experience of using the site improved but the back-end problems didn't, it's possible to imagine press coverage moving on. That would be a disaster.The White House view
To understand why these problems are so dangerous to Obamacare it's helpful to understand how the Obama administration thinks about Obamacare.
With my colleague Sarah Kliff, I spent much of May and June working on that. What we wanted to know -- and asked repeatedly -- was how administration officials defined success for the health care law.
Here is what we learned: “To the White House, the difference between success and failure is straightforward: They need to entice a sufficient number of young and healthy adults into the new insurance marketplaces that open Oct. 1.”
I want to be clear on this: No one said that success was letting kids up to age 26 stay on their parents' insurance plan. No one said it was regulating insurers or covering preventive care. Instead, everyone in the White House shared a singular definition: Success meant setting up the exchanges and attracting enough young people that premiums stayed low.
This was true even when the conversation turned to Medicaid, which is responsible, in theory, for half of the health-care law's coverage expansion.
The Medicaid problem
The problem for Medicaid is that a lot of red states are flatly refusing to participate, which means millions of low-income people who need health insurance and are eligible for it under the law aren’t going to get it.
The White House didn’t believe those red states could hold out very long: The Medicaid deal was simply too good: The federal government pays 100 percent of the costs for the first three years and 90 percent thereafter. Refusing free federal dollars is hard for even the most hard-core ideologue, which is why conservative governors in Arizona, Florida and Ohio have battled their Republican legislatures to sign their states up.
The remaining red states would fold, the White House assumed, as soon as Obamacare was seen as a success -- or at least seen as permanent. But for that to happen, the insurance exchanges -- the law’s most visible, ambitious and far-reaching innovation -- would have to work.
The exchange problem
The key to the exchanges was getting enough young and healthy people to turn out. The reason is simple: Insurers price their products at the average expected cost of the people signing up, plus a bit more for overheard, profits, etc. So if the average person signing up is relatively sick, premiums rise. if they're relatively healthy, premiums fall.
Sicker, older people, the administration figured, would be desperate to sign up for health insurance. In a sense, that was the problem: They'd be so eager that they'd sign up in much greater numbers than the young, healthy people needed to keep premiums low. Attracting those young and healthy people was thus the core challenge. The White House figured that if they got 7 million people to sign up for the exchanges in the first year, about 2.7 million needed to be young.
The Obama health-care team expended enormous effort figuring out how to reach those 2.7 million “young-and-healthies.” They modeled where they lived. They figured out which television channels they watched and which social networks they used. They learned who their important validators were. (“No surprise,” said David Simas, the White House’s deputy senior adviser for communications and strategy: “It’s Mom.”)
The White House was planning a huge campaign to get young people to HealthCare.gov. And they believed that once there, they needed a friction-free Web experience to make sure they purchase health insurance. Older, sicker folks will reload the Web page until they get through, or they’ll sign up over the phone. But the White House expected that young folks, by and large, wouldn’t tolerate a lot of hassle.
Instead, the Web experience, for most people, is all friction right now. In meetings with reporters -- and on the front page of HealthCare.gov -- the White House is talking up the ease of using the phone rather than the Web. That’s a detour that would almost certainly lead to a disastrous demographic imbalance in the exchanges.
So when Maxwell writes that "those covering the problems are insured themselves and consequently greatly underestimate the patience of a chronically uninsured person who has been counting down the days until Obamacare began," she's missing the actual problem the law faces -- the one the White House has spent all its time planning over.
The problem is precisely that the people who really need insurance will be patient and persistent. The people who don't need insurance as badly may not be. And if that happens, then in year two, costs are going to rise sharply for those sicker, older people left in the exchanges. And Republicans who see Obamacare's problems as a path to success in 2014 won't even think about expanding Medicaid.
The White House has time to right the ship. But not much. Health-care experts suggest the Web site needs to be running smoothly by Thanksgiving at the latest. And even then, it’s possible that the initial disruption will have produced a worse risk pool in year one, leading to higher premiums in year two. In that way, the amount of help that this program will deliver to the people who need it most, at least in its early years, is degrading by the day.
If they just blow through the deadlines entirely it doesn't mean the entire program unravels. But it does mean that it will do a much worse job helping people for years. It does mean that there will be fewer people on Medicaid and many more people paying premiums they can barely afford, or, in some cases, that they can't afford at all.
Obamacare isn't a political abstraction any longer. Its success doesn't depend on spin or solidarity. What matters for the law -- and for the people who are depending on it -- is how well it actually works. So far, it's not working well at all. If and when that changes, our coverage of the health-care law will change, too.