BROOKS: Health care chaos straight ahead

Keywords Forefront / Opinion
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David BrooksIt was always going to be difficult to implement Obamacare, but even fervent supporters of the law admit that things are going worse than expected.

Implementation got off to a bad start because the Obama administration didn’t want to release unpopular rules before the election. Regulators are overwhelmed. Republicans in Congress have refused to provide enough money for implementation.

By now, everybody involved seems to be in a state of anxiety. Insurance companies are trying to put out new products, but don’t know what federal parameters they have to meet. Small businesses are angry because provisions that benefited them have been put on the back burner. Health care systems can’t plan without a road map. Sen. Max Baucus, an author of the law, says he sees a “huge train wreck” coming.

I’ve been talking with a bipartisan bunch of health care experts, trying to get a sense of exactly how bad things are. In my conversations with this extremely well-informed group of providers, academics and former government officials, a minority, including some supporters of the law, predict Obamacare will collapse and do serious damage to the underlying health system.

But the clear majority, including some of the law’s opponents, believe that we’re probably in for a few years of shambolic messiness, during which time everybody will scramble and adjust to a new normal.

What nobody can predict is how health care chaos will interact with the political system. There’s a good chance Republicans will be able to use unhappiness with what is already an unpopular law to win back the Senate in 2014. Controlling both houses of Congress, they will be in a good position to alter the program.

The law’s biggest defenders will then become insurance companies and health care corporations. Having spent billions of dollars adapting to the new system, they are not going to want to see it repealed or replaced.

The experts talk about the problems that lie ahead in cascades.

First, there is what you might call the structural cascade. Everything is more complicated than originally envisioned. The Supreme Court decision made the Medicaid piece more complicated. The decision by many states not to set up exchanges made the exchange piece more complicated. The lines of accountability between, for example, state and federally run exchanges have grown byzantine and unclear.

A law that was confusing has become mind-boggling. That could lead people to freeze up. Insurance companies will hesitate before venturing into state exchanges, thereby limiting competition and choice. Americans are just going to be overwhelmed and befuddled. Many are going to stay away, even if they are eligible for benefits.

Then there is the technical cascade. If the data process looks like some 1990s glitchmonster, the public opinion hit will be catastrophic.

Then there is the cost cascade. Nearly everybody not in the employ of the administration agrees this law does not solve the cost problem, and many of the recent regulatory decisions will send costs higher.

Then there is the adverse selection cascade. Young people may decide en masse that it is irrational for them to get health insurance that subsidizes others while they are healthy. Without premiums from the young, everybody else’s costs go up even higher.

Then there is the provider concentration cascade. The law further incentivizes consolidation of hospitals, doctors’ practices and other providers. That also boosts prices.

The turmoil around Obamacare could dominate politics for another election cycle, and the changes after that—to finally control costs, to fix the mind-boggling complexities and the unintended consequences—will never end.•

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Brooks is a New York Times columnist. Send comments on this column to ibjedit@ibj.com.

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