Monday, May 27, 2013

One Small Point on ACA Implementation

I have a post up at Plum Line about a familiar topic to regular readers here -- that Affordable Care Act polling now is unlikely to predict much about how people will react to the law once it's implemented.

I'll add one more point, however. There's a possible press bias involved which might help the ACA. For the most part, the people who are helped the most the Obamacare -- people who did not have health insurance, wanted it, and will be able to get it through the exchanges, in many cases with subsidies that really will make it affordable -- are not opinion leaders. There's one exception, however: freelance political reporters, bloggers, and columnists should be big winners from the ACA, and can make a fair amount of noise.

Now, of course, if Obamacare really does turn out to be a disaster, that won't matter much -- indeed, if full-time employees of large newspapers and magazines wind up losing insurance and the exchanges are difficult to navigate and deliver an inferior product, then the press will collectively wind up turning against the program. But if that's the case, it won't really matter, because everyone will hate ACA if it's an across-the-board disaster.

I've talked before about another bias which should hurt Obamacare approval after implementation; the press tends to have a bad news bias, in which things functioning smoothly is boring and therefore not news, while glitches and snafus make for good stories. And we've already seen, and should see more of Republicans blaming anything that ever goes wrong with anyone's health care or insurance on Barack Obama and the Democrats. So I have no idea how big a deal this counter-bias might be, but it's at least worth a little mention as implementation continues.


  1. "There's a possible press bias involved which might help the ACA."


    This is the funniest thing I've ever read on this blog. Even funnier than Turley's recent article with his "hey! It seems like career civil servants have a lot of power!"

  2. Bad News Bias - wasn't that a Little League movie?

  3. p.s. I wonder how many reporters are either a) under 26 and on their parents' healthcare plans, or b) have an adult child under 26 on their healthcare plan.

  4. As you noted, if massive dumping occurs or the exchanges become excessively complicated (for whatever reason), that's a story that writes itself. AFAICT, there's one other major risk of the ACA/universal health insurance: normalizing everyone's health care potentially imposes a cost on those currently on the happy side of the US health care divide. This last concern may affect specific individuals, but it won't be an easy story.

    For example, if the (don't call them) "death panels" make decisions deleterious to your relative's well-being, and they wouldn't have done so previously, that's a counterfactual that's hard to quantify. Sort of like Krugman saying that the economy is not great with stimulus but would have been worse without it, maybe, but who can say for sure? So it will be with the death panel-type decisions in the great health care future.

    As a result, I think it's right that we needn't worry about the media guiding reaction to the ACA: either there will be a big disaster that will write itself, or there will be many subtle indignities that don't make great copy.

    1. CSH, I think you need another cup of coffee, because you haven't woken up and faced the real world yet this morning.

      Here's what the IPAB is mandated to do: they identify best working practices in medicine, and pay for those. You're thinking it'll sound like the corporate world we're all used to; i.e. there's a very expensive operation that might cure your disease, but we won't pay for it.

      Instead, it'll sound like this: Are you going to order an MRI? No, for this you won't need one. Instead, you'll get.......

      IPAB works by strengthening the doctors' authority, not by countermanding it. They will soak it up like a sponge, which will make it invisible.

    2. Think of it this way: as you note, IPAB is tasked with finding cost savings without compromising care. The real win won't come from limiting MRIs (which your Big Health Insurance already does, and the cost of which your health insurer has already massively squeezed). Perhaps the most fertile ground will be the inflated reimbursement to specialists.

      Reigning in the reimbursement to specialists will not be a Palin-esque death panel, certainly. It will also be, as you suggest, invisible. We may even meet again in 2-3 years' time, and you will say, WTF CSH, where are your vaunted 'death panels'? I will reply: well, nowhere, of course.

      A week later, we'll talk again, only this time the conversation will be what happened to all the specialists, and why is it so much more difficult to see one than it used to be five years ago? Not a death panel. At least for public copy.

  5. So you predict that all the specialists will stop practicing medicine?

    Or do you predict that more doctors will become GPs, since being a specialist will no longer pay so much?

    Or do you predict that fewer young people will want to be doctors?

    Will the IPAB reduce payments to specialists, or will they allow GPs to perform procedures that specialists used to do?

    If it's the latter, it might become easier to get an appointment, as they will only see the cases that warrants their expertise.

    1. These are all good questions, probably beyond my paygrade - I suppose any and all of your hypotheticals are possible, in some mixture. In general, I was arguing that shifting to universal delivery of health care, at lower total cost, must compromise the per-person access somewhere, but to this conversation, it may not be easily identifiable where the compromises have occurred.

      Something else interesting occurred to me today: probably the biggest risk to successful ACA implementation is large corporations responding to financial incentives to dump en masse, overburdening the exchanges (and ultimately the polity). As Jonathan points out, we have no idea whether this will happen until it either does or doesn't.

      The strongest force stopping companies from dumping en masse is that employees will hate it. Companies have a long and storied history of taking profits to the bottom line while screwing workers; in this case the shaft is particularly bad, especially for those workers not qualifying for a subsidy.

      And here's the interesting thing: the fact that 50% of Americans virulently despise the ACA may end up protecting the worker health care system. 50% (probably more) of any large workforce surely also deeply despise the ACA. Even if no one thought through the financial implication, this should give BigCo pause about throwing such employees on the exchange.

      Isn't that fascinating? Its entirely plausible that the thing that saves the ACA is the fact that so many Americans so desperately want to kill it.

    2. Eh. It's certainly not true that 50% of Americans "virulently despise the ACA." It's probably around 20%, 30% tops. And of those, a lot of them despise either purely fictional portions of it, or taxes, or Medicare cuts. The number who despise the exchanges is, I'm guessing, if not zero then fairly close to it.

      I expect that two years from now lots of partisan Republicans will still hate Obamacare but will consider the exchange through which they sign up for health insurance to be just a normal, boring, part of the health care system which has always been there.

    3. I think that's right, JB. It might be rather like Democrats who despise Wal-Mart. They grumble and grouse. They may even take action by, for instance, protesting changes in zoning codes to allow more Wal-Marts to be built, or trying to cut off some of Wal-Mart's tax advantages and regulatory protections. They certainly denounce it as the spawn of Satan every chance they get. But they shop there, and if they couldn't shop there (which is to say they had to pay the prices that small local stores that they profess to love would charge), they would howl in anger. Mostly, it just gives them a symbolic but not particularly practical subject to grumble and grouse about.

      With the GOP and Obamacare, that point may be reached when state governments try to find ways of taking the Medicaid money without looking like that's what they are doing. Maybe it will be part of some kind of symbolic Medicaid "reform" that allows the
      red states to claim a victory on restraining Medicaid costs while taking their payday.


Note: Only a member of this blog may post a comment.

Who links to my website?