When It’s Complicated

There’s always an out. When you really don’t want to explain why you’ve done this or that, or why you’re nothing, you just use the magic words – it’s complicated. That doesn’t work very well with enraged girlfriends or spouses, even if all those chats with that other woman were entirely innocent, or close enough – but it works quite well otherwise. Most people want simple answers, not because they’re simpleminded, but because life is complicated enough as it is and they fear overload. So say it’s complicated, and you need to explain the historical background of the issues involved, and then the current factors at play, and their relative importance, and then who the major players are and their motivations, and then the initial sequence of events that started all this, this time, and then pull out a pad of graph paper and four or five different colored pens… and that curious or outraged person will soon enough tell you to forget it. They really don’t want to know, but then sometimes things actually are complicated. There’s no way around it. Someone will ask you to give them the simple answer, damn it, and there is no simple answer.

That’s always been the problem with the Affordable Care Act – Obamacare. It was pure hell to pass – the Republicans fought it all the way – and no one was quite sure it would survive the Supreme Court challenge – but it did. Now it’s the law of the land – there’s no ambiguity about it, even if no one quite understands it. It really is complicated, or it’s not. The federal government mandates that you buy health insurance, if your employer doesn’t provide it or if you’re self-employed or unemployed – otherwise you pay a fine. If you cannot afford health insurance, the government will provide a subsidy so you can. The states will set up insurance exchanges where you can shop for policies, and in the states have flatly refused to do that the federal government will set up such exchanges. This is to assure that almost all the population will eventually have some sort of rudimentary healthcare coverage. A healthy populace is a good thing – prevents epidemics and that sort of thing – no one dies in the street, or shows up in the emergency room for free care, as mandated by that law Reagan passed back in the eighties, which is driving many hospitals out of business. The deal is good for the insurance companies too – in exchange for many tens of millions of new paying customers, all they have to do is play by the new rules – they can’t refuse to insure someone because of preexisting conditions, or drop them when their care becomes too expensive for the bottom line, and they have to cover a normal range of services – they cannot say they only cover hangnails, not birth control or diabetes. It’s a trade-off. What they lose in actuarial control – only insuring those unlikely to get sick, and paying only for what’s inexpensive – they gain in volume and scale, where the few expensive folks are a minor matter in the much larger risk-pool. It’s not a bad deal.

It’s also not that complicated, in broad terms. It’s a way to phase out a system where your employer provides healthcare coverage, for which you pay a big chunk, or doesn’t and you have to buy what you can on the open market, where no one really wants to insure you anyway. That left forty million or so of us with no healthcare at all – save for that desperate trip to the emergency room – which was bad for everyone concerned. The counterargument was that you should get a good job, with benefits, or else take care of yourself. If you can’t afford what’s out there, or no one will insure you at any price, that’s your problem, not the government’s problem. It’s a matter of personal responsibly. Take personal responsibility or die – that’s how real life works. Stop whining, and if you do live long enough you’ll get your damned Medicare, and Medicaid is there with a few bucks if you’re totally disabled or desperately poor – even if those are a bit evil in that socialistic way too. Additionally, the government shouldn’t be telling insurance companies how to run their business, making up new rules they have to follow. That is socialism. Or it is close enough.

Those arguments didn’t prevail. No other industrialized nation in the world claims any of that makes sense – they all have systems that assure a relatively healthy population, which they seem to think is quite useful. You don’t leave such things to chance or to the whim of the free market, where everyone is out to make big bucks any way they can. The government takes care of such things, so the populace can go do other useful things and prosper, with one less thing to worry about. That’s a concept with which we’re still struggling. Should the government be in the business of removing barriers to prosperity? What about moral hazard? Sooner or later people will feel they’re entitled to this and that and the other thing. They’ll go soft.

Add to that what we’re trying here really is complicated. This is not socialized medicine. This is a subsidized free-market medicine, with a set of complicated rules for the players, which some will think are fine and others oppressive. It’s an awkward hybrid, which is probably why we had an angry period of arguments about policies covering birth control and family planning. That’s standard stuff in almost all health plans, but now Catholic organizations didn’t want to be forced to offer either, even to their non-Catholic employees, because that would make them complicit in what their religion says is as immoral as immoral can be – birth control is the moral equivalent of murder, and family planning should be left to God, and sex, except for making children, is disgusting and evil. Making them follow the general rules violated their religious freedom, and this was clearly a case of the government attacking religion, or God himself. The evangelical social conservatives, and then most of the Republicans, jumped in with the Catholic bishops, as did Rush Limbaugh, with all his talk of sluts who popped birth control pills like they were candy. It was a mess, and an easy compromise was worked out, but the devil is always in the details. Obamacare really is complicated.

Now we’re at it again, because The Affordable Care Act includes a provision penalizing employers with more than fifty full-time workers who either don’t offer health insurance or whose employees who can’t afford insurance without taxpayer help. Those penalties begin in 2014 – that’s what the law says, except the Obama administration just said no, we’ll do that the next year. Everyone was surprised, and the Republicans were quick to say this proves that Obamacare is so complicated it can’t even be implemented – it’s a train wreck and we should repeal the whole thing, right now.

Maybe, but it seems that Team Obama has now decided to give businesses more time to comply with the reporting requirements:

“We have heard concerns about the complexity of the requirements and the need for more time to implement them effectively,” Mark J. Mazur, an assistant Treasury secretary, wrote on the department’s Web site in disclosing the delay. “We recognize that the vast majority of businesses that will need to do this reporting already provide health insurance to their workers, and we want to make sure it is easy for others to do so.”

That’s bland, and Jared Bernstein, an economist, adds this:

Though the mandate will ultimately affect only a few employers, it is actually an important piece of the law’s architecture. Without it, employers who currently provide coverage to their workers could drop the coverage and send their workers over to the state health care exchanges. And since some of those employees would be eligible for subsidies to help defray the cost, the employer would be shifting what is now a private cost over to the government.

The penalty for such actions was supposed to kick in next year; now they’ll kick in the year after next. The government needs a bunch of information from businesses to determine if the penalty is warranted, and the White House is now saying that putting that reporting process in place is going to take longer than expected.

It’s complicated, but Bernstein doesn’t see this as a big deal:

The important coverage aspects of the Affordable Care Act – the Medicaid expansion and the state health care exchanges – are still scheduled to be up and running by Oct. 1, the beginning of the fiscal year (of course, not every state has accepted the Medicaid part). And the requirement to have health insurance or pay a penalty – the individual mandate – will still take effect in 2014.

And a vast majority of employers with at least 50 full-time workers – about 95 percent – already offer coverage to the workers. With the exchanges going up, there’s a chance some employers could try to pull off the cost shift noted above, but the mandate will be in place by 2015, so we’re unlikely to see much of that.

At least one report suggests a budgetary cost from the delay, since the revenues from penalties would flow to the Treasury Department. But a colleague who tracks this stuff very closely tells me that while the Congressional Budget Office earlier this year scored this part of the bill as providing $5 billion to the Treasury next year, its most recent score dropped that to zero. The budget office appears to have wisely assumed it was already going to take a while to get this part of the system up.

So, no budget cost, little impact on coverage.

Ah, it is complicated, but not significant, except that it is:

Is this delay just not a big deal? Um … this is Washington, folks, and we’re talking Obamacare. There will be much hay made of this delay in coming days. Conservatives will argue that this confirms that the law is unmanageable – which is a bit rich, since many of them have been trying to kill it, block it, and stop it in its tracks. (Speaker John Boehner’s press secretary, Brendan Buck, on Twitter: “Obamacare. Such a train wreck.”) Liberals may argue that the administration is caving to business, which just wants to put off the paperwork for a year.

I think it’s an unfortunate delay of an important but relatively small piece of the bill, more growing pains of the type I’m sure Medicare had when it got going than anything existential. But that’s not how it will play in the hurly-burly of the next few days of Washington politics.

He’s right, as talking Points Memo’s Brian Beutler reports here:

The decision to delay it for a year sidelines one liability that would have harmed the law’s rollout, robs Republicans (temporarily, but during an election year) of a legitimate public critique of the law’s real-life effects, and ironically strengthens the state-based insurance exchanges, which are the must-work components of the ACA.

Thus Republicans are torn between a feeling of satisfaction that the administration has effectively copped to the employer mandate’s problems, and of frustration that a problematic provision won’t be taking effect right away, before next year’s midterm elections.

“I want to know why, after repeated assurances that everything was on track and that no more deadlines would be missed, that the Administration has taken this action,” said Rep. Kevin Brady (R-TX), the chair of the House Ways and Means Health Subcommittee, in a statement accompanying the announcement of a July 10 hearing on the delay. “It is time for the Administration to explain to the American people why it’s acceptable to grant this delay, while at the same time taking no action whatsoever to provide any relief from the individual mandate.”

It’s all fuss and nonsense:

Republicans like Brady are predictably using the employer mandate decision to argue that other, more consequential measures in the law – like the individual mandate – should be delayed as well. But it doesn’t take much reading between the lines to recognize what’s really going on. Republicans are still committed to the far-fetched objective of repealing Obamacare, and as such have effectively vowed not to work with the administration to fix any of its dysfunctional provisions. To the contrary, the GOP is committed to creating implementation problems where they can, and to making sure existing problems are never fixed, to make the whole program a liability for Democrats.

By delaying the employer mandate, the Obama administration unilaterally sidestepped the GOP’s strategy. And Republicans aren’t happy about it.

“This Obamacare deal just enrages me,” tweeted Josh Holmes, chief of staff to Senate Minority Leader Mitch McConnell (R-KY). “Admin frantically working to avoid accepting consequences for a disaster they created.”

In other words, even though the policy is fixable, it should be implemented as is, on schedule, so that the White House either pays a political price for it, or agrees to full repeal.

Ah, it’s complicated, and needs some adjustments, but people hate complicated things. Yes, say something is complicated and people recoil, at least that’s the bet here, except it’s a bad bet:

Some conservatives have even considered the possibility of taking legal action to prevent the delay, but the administration hasn’t explained the legal rationale for the decision, and even if that rationale turns out to be wanting, it’s unclear who would have standing to sue the Treasury Department.

So for now, the real outrage is trained on the delay’s substantive and political ramifications. And the dynamic can be summarized pretty simply: the employer mandate hiccup ironically increases the chances of a smooth rollout and that scrambles the GOP’s worse-is-better view of the implementation process.

Slate’s David Weigel takes it from there:

On Wednesday, the House Energy and Commerce Committee sent letters to the relevant agencies, asking why they’d failed and lied and failed about the employer mandate. The committee’s Republicans wanted, among other things, “all documents and communications, including e-mail, between administration officials and any individuals, companies, or organizations discussing the requirement that employers provide coverage to their employees.” They wanted this within two weeks. Got it? Thanks!

As high-profile where-are-the-bodies investigations go, this one’s fairly promising. Republicans are right: The administration oversold the ease with which businesses employing more than 50 full-time workers could comply with a health care mandate. That’s about 4 percent of all businesses, and HHS Secretary Kathleen Sebelius juggled waivers for the holdouts but otherwise promised that all was well.

Yes, but this is a dry hole:

The Obama Treasury Department delayed the mandate because it knew Congress wasn’t going to fix it. Republicans don’t want to tweak the law as much as they want to bind it in chains and set it on fire…. Their strategy in 2009 and 2010 was to stop it from passing. Their strategy in 2011 and 2012 was to win an election and repeal the law.

Their strategy today is both to win an election and repeal the law, and to have it collapse in failure. Today’s GOP is approaching TED levels of innovation in undermining the law. In June, for example, Mitch McConnell and John Cornyn, the party’s leader and whip in the Senate, sent letters to the NFL, NHL, NBA, PGA, and NASCAR asking them to please, please not help the administration advertise the Affordable Care Act. Sure, the Red Sox had helped advertise “Romneycare” in Massachusetts – but this was different. “Just this week, a Gallup poll showed that a majority of Americans disapprove of Obamacare,” wrote McConnell to Roger Goodell. “The Massachusetts law was adopted by large bi-partisan majorities in a Democratic legislature and signed by a Republican governor. Obamacare was passed on a party-line vote, using extraordinary legislative gimmicks and widely ridiculed political favors to win passage.”

Now, was there some American whose opinion of Obamacare would be totally changed during the Packers-Giants game? Probably not, but that’s not the point: Republicans have taken every chance to shrink the Obamacare PR campaign. They deleted the law’s PR budget, and then raised hell about the administration moving around money and asking for help from private firms to promote it.

That’s only part of the effort:

The multistate rebellion against the law’s Medicaid expansion money (the Supreme Court decision that saved the ACA made the Medicaid buy-in optional) is undermining the law itself. Any conservative will tell you that the states refusing the money are trying to make the law impossible to enact. “Texas will not be held hostage to the Obama administration’s attempt to force us into this fool’s errand,” said Texas Gov. Rick Perry, who, according to polls, could still be governor through 2018.

If they take the Medicaid money, finally allowing the remainder of the poorest of the poor and the disabled in their state finally to have access to at least some healthcare, the rest of Obamacare will work just fine – so we can’t have that. Rick Perry has an odd concept of who is holding whom hostage, but there’s more:

If Republicans have 51 votes in the Senate come 2015, they’ll try to repeal the taxes in Obamacare in their first budget. Since any such vote would need to be scored as deficit reduction, that might not be possible, but hey, maybe the ascension of President Chris Christie in 2017 will fix that. Look at how successful they’ve been in Wisconsin or North Carolina, where total control of the legislature has undone decades of labor and civil rights laws.

If this seems nihilistic, please, pay more attention. Every high-level Republican strategy comes down to “just stop the Democrats and win later.” There’s a growing conservative consensus to stop immigration reform because Democrats can’t be trusted in the conference committee. “I think some of us who think it’s a bad bill should probably do a little work to make sure it stays dead, dead, dead,” said Bill Kristol last week. “Here in Washington, these bills can emerge, zombie-like, you know?” The appetite for replacing the cuts of sequestration is pretty well gone, to the surprise of Democrats.

This is broader than it seems, and it is a plan, even if a half-assed one:

None of this is crazy. It’s practically the duty of the out-party to make a lame duck president limp as soon as possible. Some Republicans think they did that when their Senate minority denied an up-down vote on gun control, and more of them think that the president is now too plagued by scandals to pressure them in their states and districts.

But he’s still the president. Promising not to make any deals with him doesn’t shrink the size of government. Government keeps growing, and the president’s the only player who can influence it. Sequestration consisted of random cuts, so agencies cut conferences and gave days off instead of actually restructuring. There’s no chance of a climate bill coming out of this Congress, so the president’s just rolled out more carbon regulations. Republicans criticize these “power grabs,” and they plan to campaign against them, but they don’t actually stop them.

They haven’t even stopped the employer mandate.

Yeah, that particular mandate is complicated, and the administration announcing that they were taking time to get it right was a surprise, but Weigel sees it this way:

Republicans were right, so they get gloating rights, but for now, nothing else.

They wanted to keep it simple – everyone likes simple – but sometimes things just aren’t simple. That does seem to be the trouble with the Affordable Care Act, but that doesn’t mean it’s a lousy idea. The next time someone says it’s completed, don’t shut down. Sometimes that’s good.

About Alan

The editor is a former systems manager for a large California-based HMO, and a former senior systems manager for Northrop, Hughes-Raytheon, Computer Sciences Corporation, Perot Systems and other such organizations. One position was managing the financial and payroll systems for a large hospital chain. And somewhere in there was a two-year stint in Canada running the systems shop at a General Motors locomotive factory - in London, Ontario. That explains Canadian matters scattered through these pages. Otherwise, think large-scale HR, payroll, financial and manufacturing systems. A résumé is available if you wish. The editor has a graduate degree in Eighteenth-Century British Literature from Duke University where he was a National Woodrow Wilson Fellow, and taught English and music in upstate New York in the seventies, and then in the early eighties moved to California and left teaching. The editor currently resides in Hollywood California, a block north of the Sunset Strip.
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