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Life Health > Health Insurance > Health Insurance

On the Third Hand: Piecemeal

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Sometimes, reporters make a name for themselves by hanging out in bars — or maybe in caves — with government officials to ferret out riveting tales of corruption and bitter infighting.

For me, getting pretty good scoops on the implementation of the Patient Protection and Affordable Care Act has sometimes involved something as simple as opening the ZIP file containing a draft of some PPACA exchange enrollment form or another.

Obama administration officials have a habit of burying interesting PPACA information in plain sight on, say, page 100 of a draft of proposed regulations implementing Section Jillionty-Zillionty-Forty-Five of PPACA Section XYZPDQ.

I have not yet gotten any PPACA scoops by reading notes distributed through wine bottles, but that’s probably just because I have not spent much time on the banks of the Hudson River looking for wine bottles.

Officials took that kind of piecemeal approach of communicating PPACA information to a new level Tuesday by announcing a one-year delay in the effective date of the PPACA employer health mandate coverage provisions through a Treasury-only blog entry.

Not through a press release. Not through an announcement featured on the website of all of the three major PPACA implementing departments — the Treasury Department, the U.S. Department of Health and Human Services, and the U.S. Labor Department.

Not through a notice fed into the Federal Register publication system.

Not even through some kind of accidental, or even pretend accidental, remark made during some kind of in-person event.

But through a blog entry with the uninformative headline, “Continuing to Implement the ACA in a Careful, Thoughtful Manner.”

Whether you love PPACA or hate it, I think everyone can agree that simply trying to figure out just what all of the various arms of HHS, the Treasury Department and the Labor Department are doing — or think they’re doing — about it has become a maze-scavenger hunt hybrid. 

And knowing what those agencies are doing doesn’t necessarily give you much help with understanding what state exchanges, state insurance departments, state health departments, state CO-OP plans, or the U.S. Office of Personnel Management Multi-State Plan Program are doing.

On the one hand: I lost the scavenger hunt race yesterday (the Treasury Department website is generally not a prime source of PPACA beat material), but, usually, the “find the tidbit” system has been great for my article view counts.

On the other hand, the tangled cloud of notices, drafts, regulations, letters, data resources and final versions of guidance does not inspire much confidence that PPACA implementers are actually implementing the law in a way that they understand, let alone in a coherent, fair, transparent way.

Maybe the cloud reflects the reality that members of Congress saddled the Obama administration with a law that’s just plain hard to implement.

It seems as if it’s time for the administration and state implementers to get into a big room with the federal and state exchange contractors and figure out what they can really do by Oct. 1 or by Jan. 1, 2014, what they have to put off, and what they have to admit is not actually possible to do.

Of course, PPACA opponents want to use the delays as a new opportunity to kill PPACA altogether. Even for people who hate PPACA, I think repealing it or crippling it is a bad idea.

People in the health insurance industry have known that the current version of the U.S. health finance system was in trouble since the health maintenance organization utilization management programs fell apart in the mid-1990s.

Ten or 15 years ago, even the leaders of groups like the National Association of Health Underwriters and the America’s Health Insurance Plans were proposing PPACA-exchange-like programs as the solution to the nation’s health finance woes. 

One problem is simply that no one knew how well or poorly the programs would really work in a system that included mechanisms for controlling anti-selection risk and related types of risk.

Letting PPACA take effect in some reasonably coherent form — at least in states like California and New York that actually like it — is one way to get information about what definitely will or definitely won’t work.

Some will say, “But PPACA is doomed!”

Well, yeah. So is the current system. The best possible outcome of implementing the PPACA I changes is getting that folks can use to design a better PPACA II when PPACA I World falls apart.

If PPACA I is repealed entirely: Then PPACA I itself won’t destroy anything, other than what it’s already destroyed — but we won’t get any useful information about what new approaches might or might not, and the same forces that have been destroying the existing system will continue to destroy the existing system.

If PPACA I comes to life as a deformed, misshapen creature: We’ll end up with 50 years of he said-she said arguments about whether PPACA I changes would have worked if the Republicans had been nice.

If PPACA I comes to life in some kind of half-way coherent form: We’ll probably be miserable, but we’ll learn something about what makes us miserable.

On the third hand, whether we kill PPACA, simply cripple it, or let it stumble to whatever kind of full life it’s supposed to have, let’s just hope the administration does a better job of sharing the big developments with us all.

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