By DAVID BROOKS
The New York Times, January 6, 2011
The health care reform law was signed 10 months ago, and what’s striking now is how vulnerable it looks. Several threats have emerged — some of them scarcely discussed before passage — that together or alone could seriously endanger the new system. These include:
The courts. So far, one judge has struck down the individual mandate, the plan’s centerpiece. Future decisions are likely to break down on partisan lines. Given the makeup of the Supreme Court, this should concern the law’s defenders.
False projections. The new system is based on a series of expert projections on how people will behave. In the first test case, these projections were absurdly off base. According to the Medicare actuary, 375,000 people should have already signed up for the new high-risk pools for the uninsured, but only 8,000 have.
More seriously, cost projections are way off. For example, New Hampshire’s plan has only about 80 members, but the state has already burned through nearly double the $650,000 that the federal government allotted to help run the program. If other projections are off by this much, the results will be disastrous.
Employee dumping. This is the most serious threat. Companies and unions across America are running the numbers and discovering they would be better off if, after 2014, they induced poorer and sicker employees to move to public insurance exchanges, where subsidies are much higher.
The number of people in those exchanges could thus skyrocket, especially as startup companies undermine their competitors with uninsured employees and lower costs. The Congressional Budget Office projects that 19 million people will move to the exchanges at a cost of $450 billion between 2014 and 2019. But according to the economists Douglas Holtz-Eakin and James C. Capretta, costs could soar to $1.4 trillion if those who would be better off in the exchanges actually moved to them. The price of the health care law could double. C. Eugene Steuerle of the Urban Institute, who has been among those raising the alarms about this, calls the law’s structure “unworkable and unfair.”
Health care oligarchy. Since the law passed, there has been a frenzy of mergers and acquisitions, as hospitals, clinics and doctor groups have joined together into bigger and bigger entities. The drafters encourage this, believing large outfits would be more efficient. The downside to this economic concentration is there could be less competition and cost control. In many places, the political power of these quasi-monopolies would be huge, with unforeseeable results. The law bans doctors from starting up hospitals to increase competition.
Public hostility. Right now about 53 percent of Americans oppose the health care law and 43 percent support it, according to an average of the recent polls. Complaints are especially high among doctors. According to a survey by the Physicians Foundation, 60 percent of private practice doctors say the law will force them to close their practices or to restrict them to certain categories of patients.
Given this level of unhappiness, people will blame the Obama law for everything they hate about the health care system. Political opposition was fierce last November, and it could easily shape the 2012 election and lead to changes or repeal.
Over all, there is a strong likelihood that the current health care law will face an existential threat over the next five years. Each party should be preparing contingency plans.
When the crisis comes, Democrats will face an interesting choice — to patch the Obama system or try to replace it with something bigger. The administration may want a patch, but by a ratio of nearly 2 to 1, according to a CNN poll, Democratic voters would prefer a more ambitious law. Liberals could logically say that the mistake was trying to create a hybrid system, rather than moving straight to a single-payer one.
Republicans are going to have to move beyond their current “Repeal!” posture and cohere behind a positive alternative. One approach, which Tyler Cowen of George Mason University has written about, is to allow more state experimentation. Another approach, championed by Capretta, Yuval Levin of National Affairs and Thomas P. Miller of the American Enterprise Institute, revolves around the words “defined contribution.”
Under this approach, Republicans would say that the federal government has a role in subsidizing health insurance — a generous role, but not unlimited. The government would provide needy citizens with a predefined amount of money to spend on insurance and allow them to shop in a transparent, regulated, but not micromanaged marketplace.
After the trauma of the last two years, many people wish the issue would go away. But it’s not going away, especially since costs will continue to rise.
Some Congresses achieve health care; members of this Congress or the next one will have health care thrust upon them.