It seems like there’s a new story every day about a problem with the Affordable Care Act: America could turn into a country of temp workers. People could get smaller tax refunds. Small businesses won’t realize any benefits until 2015. Small business owners are confused, apprehensive, and refusing to expand.
So how bad is it? Is the Obama administration totally bungling implementation of its signature universal health care law? Is the law destined to collapse of its own weight? Or is that wishful conservative thinking?
The administration gets some surprising backup from top health officials from two Republican administrations. Gail Wilensky and Tom Scully, who ran the Medicare and Medicaid programs in the early 1990s and in the 2000s, respectively, separately told National Journal Daily that the Obama White House is doing better than they expected in putting the complex law into place. Primarily, they say, federal officials are showing flexibility with states that want to try new ways of managing Medicaid and the insurance marketplaces, or exchanges, that will come online Oct. 1.
The real problems, in the pair’s view, are embedded in the Affordable Care Act itself. There will be chaos at first, they say, and as with any complicated, large-scale change, Congress will need to pass a series of fixes. Yet they predict the law will ultimately work and become popular, and they warn their party not to count on a repeal or a fatal backlash. “Republicans are dopes for arguing this thing’s going to blow up,” Scully said. You can debate the cost and merits of the approach, he said, but “it’s not going to melt down.”
Wilensky says it’s embarrassing to have 15 percent of Americans without insurance coverage, hard on the uninsured who are medically and financially at risk as well as on communities that have to provide unpaid care. “I was not into lobbing grenades” at the ACA, she said. “Republicans had years to do it their way. When it came time for governance, it never was at the top of their list.”
Not that the two health experts don’t have problems with the law. Scully says it will be very complicated for low-income families to shift from Medicaid to the exchanges and back as their incomes rise and fall. He’s also highly critical of the amount of money being spent ($1 trillion-plus over a decade, offset by tax increases and Medicare savings) and uses words like “reckless” to describe the decision to cover an extra 30 million people overnight, on Jan. 1, 2014. “Doing it all in one shot on one day next year is pretty wild,” he says.
Wilensky predicts that new limits on how much insurance companies can charge older people will reduce participation by “young healthies,” who would essentially be subsidizing the older people. That and the phaseout of an interim high-risk pool for people with medical conditions will drive up premiums, she said. “This could really be quite the mess next year.”
The White House is bracing for trouble. “There are going to be glitches,” Obama senior adviser Valerie Jarrett said recently in response to a question from NJ Daily. “We think that the successful implementation is going to be very challenging.”
Some of the recent bad press is based on bad information. For instance, several accounts suggest that the competitive exchanges for small businesses won’t come online in 2014 as planned. But that’s wrong. The businesses will be able to shop for insurance next year in the exchanges and offer their employees a plan—in other words, just like now. What’s being delayed to 2015 is a new feature that would allow the companies to pick a level of benefits (ranging from most generous platinum policies to least generous bronze) and let employees choose any plan in that category. Big deal? Doesn’t seem like it in the context of this huge transition.
Still, uncertainty and new requirements have some small-business owners frustrated, angry, and unable or unwilling to move forward. “The regulations are coming slowly, they’re coming confusedly. Business owners can’t get straight answers and they can’t plan,” Bob Graboyes, a health economist with the National Federation of Independent Business, told NJ Daily.
Graboyes said the mandate that employers with 50 or more employees offer insurance has led to companies cutting hours and refusing to grow. “When you cross the 50 mark, at very minimum you have taken on a $50,000-a-year obligation that grows rapidly as you get more and more employees,” he said. He called the mandate “a giant Cuisinart that could chew this whole law up.”
John Arensmeyer, CEO of a more liberal business group called the Small Business Majority, said the mandate is “a real issue” for the 4 percent of small businesses it would affect, but added in an interview: “We have not seen any evidence that [businesses are] going to stop their natural growth because of this. I’m a former business owner. I can’t imagine changing my course because of this.”
There are many federal requirements that kick in at various levels. When a business hits 50 employees, for instance, it must offer family leave and report the racial breakdown of its employees. The threshold is “absolutely valid,” Scully said. “Is it bad that somebody who has 49 employees is not going to hire the 50th? Yeah, but that’s not going to happen in many cases.”