There's been a lot of back and forth about how much hardship and disruption is actually being caused by the Affordable Care Act, with tales of woe being swatted down even as other supposed horror stories pop up. But a different way to see things is that, yes, disruption is inevitable as the result of any large-scale health reform and that's simply a fact of life. Indeed, you could argue that if there's not a lot of disruption happening, then there probably hasn't been enough reform.
The simple and wise insight that disruption is inevitable was offered up in well-timed policy brief
earlier this month by Judy Feder of the Urban Institute.
Feder astutely notes that the prospect of disruption has always been the Achilles Heel of health reform aimed at bringing coverage to the uninsured. That's because the 84 percent of Americans who have health insurance would prefer not to rock the boat in a way that jeopardizes their coverage. So it was that President Obama, like President Clinton before him, leaned over backwards to assure covered Americans that it would be business as usual for them. And so it was that the Affordable Care Act built on employer-sponsored insurance (ESI), rather than trying to dismantle what is arguably a relic of the mid-20th century.
This latter point is key: The ACA is actually an incredibly mild reform in many ways, one that tweaks the status quo rather than torpedoing it. Feder notes that "it is far less disruptive than other coverage expansion strategies, such as single-payer proposals on the left and market-based proposals on the right."
Let's repeat that last point again: Some of the very same conservatives bashing Obamacare for turning our health system upside down have backed plans that, if ever implemented, would make the hurricane of the past few months look like a light breeze.
That said, Feder notes that some level of modest disruption was inevitable, and essential, to improve the pooling of risk that is so critical to the success of the ACA, and also moving people out of substandard insurance policies in the individual market. In other words, the disruption we're seeing is happening for a very good reason.
Consider this analogy: The disruption of moving is a bad thing if you've been foreclosed on. It's a swell thing if you're moving to a better house.
Unfortunately, politicians aren't such a hardy bunch when it comes to seeing through this kind of transition -- even Democrats who believe in the law. So no sooner did the disruption begin than proposals started popping up from jittery politicians to minimize that disruption. As Feder notes, though, these proposals would undermine effective risk pooling.
Herein lies a major flaw of democracy that we often comment on in this space: reforms that create winners and losers aren't just hard to get through Congress -- because the losers will mobilize against reform (as I discussed the other day regarding curtailing the home mortgage interest tax deduction) -- but are also hard to fully implement because politicians get cold feet once disruption kicks in, and losers (even if they are only temporary losers who'll actually end up better off) get another chance to throw in the sand in the gears.
These problems are bad enough in a pluralist system that isn't drenched in money and riven by polarization. But in this case, we've got billionaires, ideologues, and self-interested politicians working every day to play up the modest disruption that is occurring and stampede those jittery politicians into watering down the law.
Reform advocates can fight this propaganda, but mainly they just need to hang in there -- and convince other leaders to do the same -- until things smooth out.