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On the Third Hand: Exchange agency

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Some readers love every aspect of Patient Protection and Affordable Care Act (PPACA).

Some hate every aspect of the law, down to provisions that are even more obscure than the tanning salon tax and less closely associated with health care. Maybe some of you are burning with fury about the PPACA emerging infections prevent grant program funding.

I suspect that many are in the middle, and that some are roughly in sync with me: We just want whatever makes everybody else happy and, ideally, works as well as it can work, under the circumstances.

The whole idea of “Get PPACA-related rules, programs and agencies to work as poorly as possible, to make Democrats look bad” seems like bad policy to me, and especially unhelpful from the perspective of people who hate PPACA on principle.

See also: What some conservatives aren’t willing to do to kill PPACA

In my opinion, if you truly hate the PPACA exchange system, you should favor giving it enough funding and flexibility to show that it was doomed to fail even under the most favorable circumstances. You shouldn’t want exchange lovers to have any reasonable ability to make the argument that the exchange system failed because the haters strangled it.

Given all that, I think that, if Congress ever reaches a state such that it can sincerely try to improve the exchange system, one priority should be getting it out from under the Centers for Medicare & Medicaid Services (CMS), and out from under the parent of CMS, the U.S. Department of Health and Human Services (HHS).

On the one hand, CMS has gotten a huge new program running quickly, and, in spite of the various glitches and disappointments, there’s no clear-cut evidence that or the state-based exchanges have had any more problems than the typical private exchange program creator.

See also: U.S. sets 2016 PPACA goal at 10 million amid challenges

If anyone wants to slam CMS development and reporting efforts, and make the argument that the private sector does it better: Well, sure, CMS and HHS often sound as if they were graduates of the North Korean Academy of Glorious Communications when they report on the performance of the exchange system. But, on the other hand: Where exactly are the detailed monthly public reports coming out of any private exchange program? Where are the detailed, standardized plan selection or enrollment effectuation numbers for any private exchange program?

But, on the third hand, the idea that CMS is supposed to facilitate the marketing of exchange plans, regulate exchange programs, and run big insurance company risk-transfer programs, while, at the same time, running Medicare and Medicaid, seems to create absurd conflicts of interest.

CMS might have incentives to maximize exchange plan enrollment, even if that’s bad for the enrollees, the insurers and, ultimately, the taxpayers, if that helps hold down Medicare and Medicaid costs.

CMS might also have all sorts of conflicts of interest. Maybe, for example, decisions about exchange plan enrollment reporting standards could affect the sustainability of the PPACA three R’s risk-management programs: the reinsurance, risk corridors and risk-adjustment programs.

Maybe the need to keep insurers in the PPACA exchange system could lead CMS to playing favorites when it’s overseeing issuers in the Medicare plan market.

Maybe even putting one agency in charge of all three of the PPACA three R’s programs was a mistake. It looks as if CMS was able to reduce the well-known risk corridors program funding shortfall a bit by increasing reinsurance benefits payments. Should CMS really have been able to help one three R’s program by tinkering with another?

See also: Analyst: ‘Good PPACA reinsurance news’ is not so good

On the fourth hand, the answer may be that, under these dysfunctional circumstances, anything CMS can do to keep the plates it’s juggling up in the air is wonderful and miraculous.

But, on the fifth hand, is it a good idea to have a government so paralyzed by spite that program managers have to act like a bunch of pirates to keep their programs going?


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