One econ major. Three (or more) opinions.

Editors here got fed up with me putting phrases along the lines of “if the Patient Protection and Affordable Care Act takes effect and works as drafters expect” in my PPACA articles.

At a certain point, the editors said the disclaimers were clogging up the articles and made me take them out.

But I think the fact that I kept putting them in until my editors cracked down shows that I’ve had an accurate sense that making reliable predictions about the PPACA exchange program and other major PPACA private health insurance provisions is difficult.

A year ago, I could easily imagine that the exchange program could face information system delays, hacking, low enrollment and a death spiral. I never could have imagined that states like Oregon or Hawaii would have had such a hard time getting an enrollment website. 

This week, I see a lot of articles about opinion polls showing that consumers are skeptical about the exchange program, and that Congressional Budget Office analysts have tweaked their PPACA forecast in a way that makes their outlook on the exchange program less rosy.

Well, fancy that. Trying to change a bureaucratic, chaotic, rickety system that turned access to decent health care into a roll of the dice for many people has turned out to be controversial, complicated and erratic. Who woulda thunk!

Of course, on the one hand, all sorts of known, unknown and little-known forces could kill the PPACA exchange system quickly or slowly.

On the other hand, PPACA also could work well, in expected and unexpected ways, and improve the health insurance market and the health care delivery system in nice, self-sustaining ways. Example: I see people complaining about Summary of Benefits and Coverage (SBC) formatting details, but I don’t see anyone going to the barricades to stop The Man from imposing the infernal SBC notice requirements on us. Maybe some other PPACA provisions will be fine.

On the third hand: I think the fundamental concern about PPACA isn’t any particular technical problem with websites, or even ordinary actuarial illiteracy in, say, the PPACA risk-management programs. A teeny bit of (actuarially assisted) bipartisanship could melt many of those ice dams away.

I think the fundamental problem is that the world is a lot nicer when benevolent government agencies have a love-hate relationship with the bean counters at insurance companies, instead of being the bean counters themselves.

In a free commercial market, or a free marketplace of ideas that pits government agencies against private companies that are big enough to stand up for themselves, the commercial market and the marketplace can help put some limits on how tough insurance companies can be for how long, just as the investment markets and bill collectors put limits on how generous companies can be.

If a powerful government agency is the company and its own regulator, then it can have the pleasure of wallowing in flowery rhetoric about how nice everything should be and how generous it is, then stick it to the insureds.

See, for example, Medicaid. It promises the moon and gives the enrollees a slice of processed cheese.

That thought hit home a few weeks ago, when I was reading about U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius openly rallying exchange helpers to bring in “Young Invincibles,” and again yesterday, when I was reading about an HHS recommendation that PPACA exchange plan insurers put a ban on age discrimination in exchange agent contracts.

So, OK, HHS may knock a few exchange agent heads together if it hears of complaints about age discrimination… but HHS officials can go around the country trying to get exchange helpers to bring in healthy Young Invincibles.

Sounds to me as if what HHS does when it’s really in charge of insurance conflicts with what it says when it’s the regulator.

See also: