Wednesday, December 4, 2013, Amazon, and Health Care as Normal Politics

I made the point yesterday that what we're starting to see is the re-emergence of health care as a normal political issue, along with the end fight over passing and then repealing the ACA.

I think that's the right lens through which to understand the conversation about the remaining visible problems at as discussed by Jonathan Cohn and others. Philip Klein, criticizing the improved web site, noted that it still compares unfavorably to typical commercial sites; Cohn considers the evidence.

Here's the thing, though. None of this has anything at all to do with the "success" or "failure" of the ACA. Yes, if Amazon was down every night for scheduled repairs and then occasionally the rest of the time, Amazon wouldn't last long. But, as I said the other day, not a single state motor vehicle registration or driver's licence program has every failed because local DMVs are typically a mess.*

Which doesn't mean it won't matter, going forward, whether is well-run or not. It's just that it will be a normal political issue. No different from whether the VA is well-run, or whether Pentagon procurement wastes a ton of money or not.

I'm confident that's true of front-end problems. I think it's probably true of back-end problems, at least within reason. Yes, it's going to be a big deal for the individual people involved if a small percentage of customers have miscalculated subsidies, or if the insurance company they thought they signed up for doesn't ever hear about it. It's the kind of mismanagement scandal that can and should create big headaches for an administration. But it's not the kind of thing that causes a government program to "fail" or to be repealed.

I suppose there might be some level at which things are so bad that customers really don't show up, or at least that effects are more than at the margins. But fundamentally, people want health insurance, and (and the state exchanges) are where people are going to go if they're on the individual market. Whether it's relatively easy or relatively difficult.**

Again: I'm not saying that mismanagement at is a non-issue. It's absolutely an issue, and a big story. It's just almost certainly a normal politics story about how well (or badly) government is working. It may even be a part of the story of the next generation of government health care reform. It's just not part of a battle over the survival or repeal of the ACA, because that battle ended a while ago.

*Is this no longer true, by the way? And is the reputation no longer true, regardless of the facts? My last experience in Texas -- in a newly opened office -- was just fine, and a few years ago I had an excellent customer experience in Indiana.

**Old guy moment: I was going to say: just as people shop at malls even if they hate malls, because that's where the stores are. Dated! And, yeah, maybe the miserable experience many people believed that circa-1980s shopping malls gave them had a lot to do with the demise of malls. But not before an awful lot of stuff was purchased.


  1. Just because ACA repeal is impossible at this point does not mean that the GOP will stop insisting that it is the Death of Freedom Itself and must be stopped now now now.

    If anything, ACA repeal might become a generation-long obsession for Republican office-seekers, generating oodles of campaign dollars while imposing very little responsibility on the candidate, because repeal will always be just tantalizingly out of reach.

    Similar to the way that Roe v. Wade, which was an unequivocal policy victory for liberals, provided conservatives with a ready-made boogeyman to rile up voters.

    So, no, this battle isn't over - even though, to anyone paying attention, the outcome has already been decided.

  2. @DMV: Depends. I had reasonably decent experiences in Maine two or three years ago, but Ohio has been hellish for me. For example, when getting my car registration changed over, I had two different clerks make three separate mistakes with copying over the VIN number in two attempts. Of course, I only had to make two attempts because the DMV folks were extra persnickity and rejected a fully notarized transferred title.

    1. The DMV experience in New York has improved immensely, although I think the wait may have begun to lengthen again.

    2. DMV in CA has gotten much better. Only one line when you get in to get routed, then you get a little alpha-numeric ID, and wait in chairs to get called via a monitor/announcement. That's if you have to go to the DMV, which is somewhat rarer with a number of things you can do via mail/online.

      That said, if you have to go in person, and the budget is bad (so they've cut back the hours)...yikes. Set aside that whole morning, if not more.

    3. But in Los Angeles, for the last eight or ten years, you've been able to make an appointment online in advance (and also, in a city that size, to choose among various locations). So I always breezed past the intake queue and was served within a few minutes of my appointment time.

  3. When I first moved to Jersey in 97, the DMV was the most dysfunctional government office I'd ever been in -- pathological, really, with personnel abusing citizens. It's completely cleaned up - orderly, professional.

  4. The website issues got ACA off to a shaky start, but it will improve. In the long run, ACA success will be judged by its results.

    Harry Reid exempting some of his staff from ACA just provided some great ammo to the Republicans. Especially when just last night on the PBS Newshour, Brad Woodhouse was arguing that all Democrats are fully united behind ACA, not running away, yada yada. It smelled funny to me then and stinks today. Essentially, I will never trust Americans United for Change again. His talking points lasted less than a day...

  5. One essential difference between the ACA and the DMV: you have to register your vehicle in order to drive it; you don't *have* to get health insurance in the exchange. Oh, you're supposed to, certainly. And you get a slap-on-the-wrist penalty if you don't. Regardless, the obligation is vastly different between the two.

    Will the disastrous launch of the website be a significant factor preventing a critical mass of young healthies from signing up? Moot point, surely. If its true, as many fear, that the critical mass of young healthies don't want to sign up, the appalling web site is a real concern.

    At this point, I think its probably a tautology that, if substantially all the young healthies sign up, the ACA will work well enough not to be a complete failure. So if our one remaining fear is the dreaded death spiral, while the flawed web site may not matter, that's far from obvious at this point.

    1. Don't get your first paragraph. I'm pretty sure that a lot of peope drive unregistered cars, drive without a license, etc.

      Strongly agree with the last paragraph. As go the young healthies, so goes ACA.

    2. I blame it on the perils of stream of consciousness - the first part of my post was supposed to say "you have to register your vehicle in order to drive it legally" - I trust that clarifies?

      On the young healthies - its interesting that ACA supporters assume compliance from those folks, for obvious reasons, perhaps. Suppose we treated their compliance not as a given but rather as the variable it surely is. And then suppose we had a brainstorming session, trying to come up with the most self-defeating ACA marketing effort to young healthies, especially since 'penalty avoidance' is not really a motivation for those folks in deciding whether to sign up or not.

      Considering that the official website is the (bit)coin of the realm for those young healthies, its sobering to consider there aren't many - really, maybe not any - imaginable marketing fiascoes bigger than the website roll-out as it actually occurred.

    3. In California, which has provided more numbers than other places, young people have been signing up in proportion to their share of the population. The problem, I imagine, is that young people in, say, Louisiana or Alabama or wherever have been getting a different message and may not try. Still, I don't think the system requires anything like full compliance from day one to survive. Eventually, more people will see the benefit of it.

  6. I'm wondering how many people are having my exchange/insurance experience. Maybe relatively few, but might be worth trying to track.
    I've been on the private insurance market for about a dozen years. I don' qualify for a subsidy.
    I shopped the state exchange here, MNSure, and found a few plans that looked acceptable. Then I shopped some of the approved state insurance providers on their own company sites. By far the plan that suits me best is a plan outside the exchange, but that I can access because under ACA, I don't have to answer any health questions.
    Overall, I consider myself to be a fantastic ACA success story ~ I'm getting a zero deductible, 10% conisurance plan for $105/month less than the expensive but what I viewed as great plan that has been canceled.
    But as a non-exchange customer, will anyone even notice? Will this be chalked up anywhere as a proper functioning of ACA, namely that competition drove down prices and guaranteed issue meant I just had to shop benefits and prices, not who would take my 48 year old mildly flawed person-ness?


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