On one matter, supporters and opponents of the Patient Protection and Affordable Care Act agreed—the days and months immediately after Oct. 1, when the new health exchanges open for business, would be bumpy. No law as complicated as the ACA has ever started without glitches and missteps.
As many as 30 million people will apply for benefits. Administrators have to provide accurate information, determine eligibility and compute subsidies. Even a 99.9% batting average means that there will be tens of thousands of mistakes.
The relevant question is not whether the new exchanges will make mistakes. Of course they will. One should be asking two other questions. First, what are people doing now to make things go well? Second, how will people deal with the problems that will surely appear?
The behavior of supporters of health reform is clear—they are trying to make things go well. In states that are running their own marketplaces—or exchanges—governors, legislators, business and labor leaders, insurance executives and professional organizations are working to get the needed administrative apparatus in place. In states that chose not to take on the hard administrative tasks themselves, the federal government is shouldering these responsibilities. Both are committed to make things work at the start, to identifying problems and to fixing them as they arise.
Experience has shown that with good will, they will succeed. Massachusetts implemented health reform legislation much like the Affordable Care Act. In the early days, there were bugs. They got fixed. The program is now running smoothly. Likewise, problems arose in 2006 when Medicare first offered coverage of prescription drugs. A lot of people were confused. But with time and hard work, the confusion diminished. Drug coverage is now an accepted and valued component of Medicare. Not incidentally, the Affordable Care Act will improve that coverage.
The lesson in both cases is straightforward: No complex law works perfectly at the start—but, with good will, things get fixed.
Some opponents of the Affordable Care Act are seeking its repeal by traditional democratic means. They are trying to win enough votes in Congress to pass a bill repealing it and to elect a president who will sign that bill. I think these efforts are ill-advised and display a stunning indifference to the fact that the Affordable Care Act will extend health insurance to tens of millions of people who do not have it now, but their methods are legitimate.
So are those of state officials who—foolishly, in my judgment—refuse to expand Medicaid coverage, even though they are depriving their residents of a large benefit that will cost taxpayers in their states next to nothing. They are making what I think is a dreadful and cruel mistake, but ours is a federal system built on state diversity.
Unfortunately, other opponents of health reform are behaving outrageously. They are actively trying to make the law fail. The health reform law provides funds to hire and train navigators and in-person assisters to help people make informed choices about what insurance plans to select.
The insurance commissioner of Georgia has pledged, in his own words, to be an obstructionist. He has said he will require these counselors to pass tests showing that they are able to perform tasks the health reform law explicitly bars them from performing. Florida officials will bar these navigators from state health offices. Missouri has barred state officials from doing anything to help people enroll and has required that counselors get state licenses before they can help people navigate the new insurance market.
Some members of Congress refuse to give constituents information to help them enroll in insurance coverage. Having failed as yet to prevail politically, they closed down the entire federal government because they failed to get their way. Next they promise to force the nation into default by failing to raise the ceiling on the national debt.
This form of protest is illegitimate. The U.S. fought a civil war over the claim of some elected officials that they could nullify federal law. Opponents of the Affordable Care Act have every right to seek its repeal. But the Affordable Care Act is the law of the land. It was duly passed by Congress. It was signed by the president. The U.S. Supreme Court affirmed its constitutionality. The American people re-elected the president who fought for its passage. As long as it is the law of the land, law-abiding citizens have a duty to obey the law.