The opportunity to be reborn is a rare gift indeed, granted to few beyond the mythical phoenix and some adherents of the Baptist faith. Them — and the Affordable Care Act, which this week will undergo what its supporters hope will be a second launch much different from its first.
Reports are flowing in that HealthCare.gov, the federal enrollment website serving residents of 36 states that didn't bother to set up their own sites, is working much better than at any time since its calamitous launch on Oct. 1.
There may still be glitches ahead, especially if the Dec. 1 relaunch brings a torrent of attempted enrollments all at once, but the feds' confidence that the worst of the consumer-facing problems are behind them seems reasonable.
Adding to the optimism are the successes of several states that did make the commitment to implement the law on their own. These include California, whose Covered California exchange reported having signed up nearly 80,000 customers for new individual health plans through mid-November and adding to that figure by roughly 20,000 per week.
The improving landscape does more than underscore the flaws in the initial rollout. It raises questions about the response to the law by its supporters and enemies alike.
The natural friends of the Affordable Care Act are Democrats, whose baby this is, and the health insurance industry, whose position at the center of the American healthcare distribution system was safeguarded by the law (much to the distaste of advocates of an expanded public role). Neither camp has covered itself in glory during the last dark months.
Democrats ran for the hills the moment the technical problems emerged with the federal website. Their panicky response to the wave of cancellations of older, noncompliant health plans only helped foster the public misconception that these cancellations would leave most policyholders without insurance or saddled with higher premium bills. (In fact, the Americans facing higher bills, especially for lesser services, are vastly outnumbered by those who will get better coverage — or coverage for the first time.)
Nor have health insurers done their part. Most seem to have withheld advertising for enrollees until the federal website is fixed and are only now preparing to launch their campaigns. That makes some sense, since there's no point soliciting customers who can't actually sign up.
But the industry has been largely silent as the act's opponents hold the floor, claiming that the website's ills translate into flaws in the conception of the ACA itself. There's the act's outlawing of exclusions for preexisting conditions. And its mandate that young adults can remain on their parents' policies up to the age of 26 — a provision that has led to coverage for more than 1.2 million more Americans and produced measurable health improvement among people ages 19 to 25.
Some of the vacuum in support and implementation of the act has been filled by community groups. "The glitches have not prohibited one ounce of enrollment in the African American community," says Barbara Williams-Skinner, co-chair of the National African American Clergy Network, which says it has reached out to 5,000 pastors across the country to promote enrollment under the act.
Williams-Skinner says the network has focused its efforts on 13 states with the largest share of the 7 million African Americans without health insurance. For many in that demographic, problems with computer enrollments haven't been very relevant. "Many in the African American community don't have computers, so it's not a big deal," she says. "They can call, they can walk in, they can do a paper application."
The real vacuum is in the Republican platform for a non-Obamacare world. They don't have one. Conservatives have vigorously spoken out about their complaints with elements of the Affordable Care Act. They've piled on about the website problems. They've resisted expanding access to Medicaid at the state level, a crucial factor in expanding access to coverage. They complain that the GOP was shut out of the congressional debate over healthcare reform in 2010.
Some of their points are fair enough, including the flaws in Medicaid, which offers doctors and hospitals inordinately low reimbursements. Avik Roy, a former healthcare advisor to the Mitt Romney campaign, has been on the warpath about Medicaid for years.
But Medicaid's shortcomings should be the beginning of the conversation, not the end, just as asserting that the Affordable Care Act "needs to go" — as House Speaker John A. Boehner's office did last week — should be the beginning of the debate, not the conclusion. The next question must be: What's your alternative?
Roy, for instance, advocates replacing Medicaid with a system of capitated care (a primary-care doctor gets a set fee per month to deliver all of a patient's primary-care needs) combined with a government-subsidized healthcare account to cover everything else. The problem, his critics observe, is that this leaves Medicaid enrollees to cover a huge amount of other services — colonoscopies, mammograms, maternity care — from their own pockets, which may be empty. "A baby will bankrupt them," observed Aaron Carroll, a healthcare analyst at Indiana University.
The House Republicans who have voted dozens of times to repeal the Affordable Care Act don't go even as far as Roy. They don't have any counter-proposals at all, other than nostrums from a threadbare GOP grab bag.
One is "tort reform." This is conservative shorthand for closing the courthouse door to malpractice lawsuits. As we've repeatedly pointed out, malpractice litigation and its consequences in "defensive medicine" account for 2% to 3% of all U.S. healthcare spending; "frivolous" lawsuits by any reasonable definition constitute a minuscule fraction of that. Shutting the courthouse door only imposes a burden on people who have been genuinely injured.
Allowing insurers to sell policies across state lines? That would guarantee a race to the bottom, as insurers hustle to locate in the states allowing the junkiest health plans — just as allowing credit card companies to charge customers the rate in the firms' home state produced a boon for tolerant places like South Dakota. California's ceiling on credit card interest: 10%. Rate on your credit card: 20% or more.
If the problems with the website really are largely fixed, most of these other complaints will fade away. In many respects, the Affordable Care Act already is becoming integrated into the American way of healthcare.
It's unimaginable that Americans really wish to return to a pre-Obamacare world. That's a world where exclusions from coverage for those with medical conditions were common, even for minor ailments; where lifetime benefit limits meant a cutoff in coverage for people with chronic or serious disease while they were still young; where arguing with your insurer over a rejected claim was a daily reality for millions.
So, yes, the rollout has been rough. But it's a mistake to think of a website as the be-all and end-all of the Affordable Care Act. Healthcare reform has come to stay.
Michael Hiltzik's column appears Sundays and Wednesdays. Read his new blog, the Economy Hub, at latimes.com/business/hiltzik, reach him at firstname.lastname@example.org, check out facebook.com/hiltzik and follow @hiltzikm on Twitter.