The Affordable Care Act is a massive piece of legislation that fundamentally transforms a massive part of the way that Americans consume health care. Its major goal, however, might be summarized this way: Obamacare massively expands access to health insurance while trying to minimize the disruption to the current way that Americans consume health insurance. The latter stipulation could either be a cop to political expediency or a genuine concern of the Obama Administration, but if not for the attempt to minimize current insurance disruption, President Obama would have probably pushed single-payer health care.
This is how we ended up with Obamacare. It's a combination of Medicaid expansion, coverage mandates, and a community rating/guaranteed issue/individual mandate/subsidies approach at both forcing insurance companies to offer "comprehensive" insurance products and forcing all Americans, healthy and unhealthy to purchase insurance. Its success relies on a number of different factors, of which a few are: enough healthy people complying with the mandate to keep prices down, insurance companies participating in the state and federal exchanges, the success of experimental cost controls, the successsful judgment of HHS technocrats in defining insurance benefits, and expanded insurance access not driving up prices for health care. If any of these concerns - or others I haven't mentioned - turn out faulty, the whole enterprise becomes tenuous.
This is why, even though Obamacare is "more than a website" as Democratic salespeople have insisted, enrollment problems threaten the entirety of the architecture. Obamacare is a Rube Goldberg structure, and one mistake here or there could prove catastrophic. Getting healthy people signed up for exchange insurance in the individual market is an important cog in the machine, and failure to do so might result in skyrocketing insurance premiums, a "death spiral," and the complete unraveling of the individual market. Combined with incentives for employer dumping of insurance and an increased load of Americans seeking insurance through the individual market, our entire health insurance system could come apart at the seams. (This is a scary possibility. But there's a chance that there are failsafes in place to mitigate death spiral effects.)
The success of Obamacare rests on a number of moving parts working perfectly together. The failed launch of Healthcare.gov has created both immediate and long-term problems for the workings of the new health system that Obamacare is trying to create.
I spoke about the workings of Obamacare with The Nation's Zoe Carpenter this week:
President Obama's promise that "if you like your health care plan, you can keep it" was an integral part of how he sold the Affordable Care Act, both to the American people and to skeptical members of his own party in Congress. That promise wasn't true, and the Rube Goldberg machine that the Democrats have turned our health system into can't suffer the "glitches" that have befallen it so far. Democrats in Congress have adopted a "fix it, don't nix it" talking point, but they also have to hope that the technocrats in charge are fast enough to repair each part of the machine as it breaks.
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