When David A. Saltzman looks at PPACA, he sees a lot of loose ends. (LHP photo)

Living in Miami and having learned Spanish as a kid, I always enjoyed the city’s multilingual nature. I particularly enjoyed being able to understand my Cuban friends and those wonderful idiomatic expressions and jokes that, while hilarious in Spanish, made absolutely no sense in English.

Six years ago, we moved from Miami to South Carolina. While there is only one language to deal with here, there are dialects that are sometimes challenging for a “halfback” such as myself (started out in New England, went to Miami and ended up in Carolina — about halfway back). I may still root for the “Dawfins,” but I know what “sweetea” is, and I am extremely pleased to live in a place where mac & cheese is considered a vegetable.

Boston has its lobstah; New Yawkers love their lunchtime “slice” or a “regular” coffee. California has its surfer-laced lingo and valley-girl speak, but Texas may beat them all. Nowhere else in our great country is “I’ll tell you wha’” considered a complete sentence.

Over the years, my Texas friends have taught me a few of their favorite idiomatic expressions. Thinking about PPACA implementation, one expression in particular keeps coming to mind: “This thing is loose at both ends and swinging in the middle.”

It’s such a better way to describe the current state of affairs than Sen. Max Baucus’s recent “train wreck” analogy. Because in train wrecks, the cars eventually stop falling off the tracks.

Journalist and Reagan speechwriter Peggy Noonan captured the current environment perfectly: “Stories of inadequacies and flaws dribble out day by day. They produce a large negative blur, and a feeling of public anxiety: what will we find out tomorrow? The administration reacts, as the president has, with protestations about how every large, life-enhancing bill has hitches and bumps along the way. But this thing looks now like one large hitch and big and never-ending bump.”

Some of the hitches and bumps are more visible than others. In February, the administration (single handedly — no help from Congress) delayed part of the requirement that some plans cap employees’ out-of-pocket costs. This has just come to light, buried as it was under a metric ton of other regulatory refuse. This is a double-whammy for consumers. Renewals are in double digits, and now they learn they will have to dig deeper into their own pockets than they were promised.

This will burden one of PPACA’s professed key constituencies: those with chronic conditions or those who need expensive medications. Marc Boutin, executive vice president of the National Health Council, said, “There is an inconvenience for some, but for other people, this will mean life-altering differences in quality of life or death, if you have certain illnesses.”

The backlash begins?
As members of the American public begin to understand how the PPACA panacea is going to work in the world — the real world — they’re expressing disapproval. A recent Wall Street Journal/NBC News poll (July 2013) reflected that 47 percent believe the law was a bad idea. That level of dissatisfaction had not been seen since 2009, which was a year before Congress passed, and the president signed, the bill into law.

A lot has happened since then, of course. From the first outright cancelation of the 1099 Tax Reporting Mandate (in April 2011) to the July postponement of the employer mandate, a delay in random checks on employee income, and the suspension of tobacco-use penalties until 2015, there has been a laundry list of “bumps.” In the aggregate, these “hitches” have driven public opinion lower — and that is just over the summer.

According to an Aug. 9 Fox News poll, 57 percent believe the way the law was being rolled out was “a joke.” Looking at polling across a variety of sources (Fox News, Gallup, Rasmussen) the inescapable conclusion is that Americans are already disenchanted with this gargantuan law. Sixty-three percent of voters believe the law needs to be changed. That question alone has shown a 5 percent increase in a month. A recent Gallup poll indicated that Americans have a negative view about the law’s future impact on their family and their country.

It is going to get worse, campers — much, much worse. Reports are beginning to trickle out about some plan design imperatives that will have up-close-and-personal impacts on all Americans. The “PPACA means free, unlimited, on-demand health care” faction is about to have its bubble burst.

To attempt to constrain costs, some of the new plans will limit the choice of both physicians and hospitals. Although early focus groups showed many would be willing to trade lower costs for more restricted networks, it will be interesting to see how quickly that willingness converts to dissatisfaction as policy and reality converge.

Old-fashioned HMO plan designs that constrain utilization and require authorization to see specialists are making a comeback. McKinsey & Company analyzed 955 consumer exchange-plan filings and found 47 percent were HMOs or similar style plans. How happy will users be to recall those wonderful days of yesteryear when they had no coverage outside their network? There are only so many cost-control mechanisms left, and this one may hit too close to home for many.

Yuxing Zheng, writing in the Oregonian, raises another compelling challenge that won’t be felt until coverage under the mandated plan designs is implemented. She writes about a woman in Cornelius, Ore., who takes care of her disabled 22-year-old daughter. The daughter suffers from multiple chronic conditions and requires 24-hour care. The mother is the caregiver and receives $1,400 a month for her efforts. The mother fears a provision of PPACA that “largely prohibits guardians from serving as the paid caregiver of an adult child with developmental disabilities.” Will the mother have to place her daughter in foster care, or will she have to transfer legal guardianship to someone else?

Additionally, the Heartland Institute recently raised some back-of-the-house complexities that will ultimately hurt those constituencies PPACA purported to help: those targeted for subsidies. They are concerned that getting married or divorced, having a child or even taking a second job might disrupt the coverage of as many as 28 million low-income Americans. Those disruptions could cause individuals and families to “bounce back and forth between Medicaid and the state exchanges.”

John Dale Dunn, M.D., J.D., policy advisor for Heartland, worries that “the Obama administration has created barriers to people in the margins receiving private health care.” He continues, “Their solution will be to expand Medicaid to include more people, until it becomes Big Medicaid on steroids. When the choices are made, they will expand Medicaid to eliminate the bouncing back and forth.” Dunn believes this is a side-step to “a government-sponsored and -controlled health care system.”

Some have been quick to dismiss those who see PPACA as a precursor to nationalized health care as “conspiracy theorists.” Senate Majority Leader Harry Reid recently spoke the unspeakable and confirmed what some of us have known for a long time: PPACA is indeed just a stalking horse for a single-payer plan. So much for conspiracies. What was just loose at both ends has now begun to swing in the middle as well.

Given the direction of the early stage polling, it is unlikely Americans will be willing to go further down the road of a health care system that is completely controlled by Washington. They already dislike the tip of the PPACA iceberg they have seen, and that dislike is growing as Americans learn more — and we haven’t even gotten started yet.

Or, as they might say in Texas, “We’ve howdyed, but we ain’t shook.”

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