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Taming the Rube Goldberg Beast That Is Obamacare

A couple posts by Sarah Kliff over at the Wonkblog franchise underline the monumental task of putting together a clumsy, interlocking, state/federal, public/private, amorphous glob of a tweak to the nation’s health care system. In fact, we’re in the midst of the Obamacare cliff, a drop-dead point where states must decide whether they want to create their own exchanges, the public marketplaces where individuals and small groups can purchase health insurance and receive subsidies, or let the federal government run them. With this deadline so close to the election, which red-state governors hoped would bail them out and remove the need to build an exchange at all, little time has been reserved for the decision-making process. So the Administration relaxed some of the deadlines.

This gives more time to set up the exchanges and meet certain benchmarks, but the exchanges go live on January 1, 2014 regardless. In fact, open enrollment will kick off next October. So all the relaxed deadline does is compress the time for implementation. Moreover, states still must inform the Administration by the end of the week whether or not they plan to go forward with their own state exchange; several states have already announced they will leave that to the federal government. The feds frankly didn’t plan on having to manage multiple state exchanges, let alone seventeen (the current number of opt-outs), yet now the task falls to them. There’s also a provision for a “partnership” exchange, with the states and the feds sharing some of the work, and you can just see that leading to confusion.

Moreover, unlike a simple public health insurance plan, which looks like an insurance company, the exchange setup is extremely complex:

“These are systems that typically take two or three years to build,” says Kevin Walsh, managing director of insurance exchange services at Xerox. “The last time I looked at the calendar, that’s not what we’re working with.” […]

These marketplaces often get described as a Travelocity or Expedia for health benefits. While that might be the case for the consumer experience, experts say the underlying technology is hugely more complex, a maze of interconnecting computer systems meant to deliver health insurance to 30 million Americans.

“The reality is, states and the federal government are building something new,” says Pat Howard, who runs state health issues for consulting firm Deloitte. “There’s a rough blueprint in terms of federal regulations, but there’s still a number of decisions that need to happen to operationalize this.”

It’s at this point that I remind you that Medicare, built in 1965 without robust computing technology and the like, took less than a year to build, with 19 million enrolled at the outset. When you add up all the exchange architecture, and the calculations for subsidies, and the need to explain eligibility and attract new customers (which means call centers and perhaps telemarketers), it becomes maddening. It’s a far cry from “turn 65, sign up for Medicare, pay a premium.” The antiquated federal IT systems can handle the latter. It appears clear they cannot handle the former.

We know now, after the election, that something called Obamacare will exist. We don’t know how well it will work.

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David Dayen

David Dayen