Health care as a necessity comes only after food, shelter and income security. The mismanagement of the website HealthCare.gov and the cancellation of millions of policies pushes an underlying question out into the open: is the federal government capable of managing the provision of a fundamental service through an extraordinarily complex system?
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This system requires coordination of over 288 policy options (an average of eight insurers are competing for business in 36 states), each with three or more levels of coverage, while simultaneously calculating beneficiary income, tax credit eligibility, subsidy levels, deductibles, not to mention protecting applicant privacy, insuring web security, and managing a host of other data points.
A malfunction at any one of these junctures could prove fatal.
In enacting the Affordable Care Act, President Obama and his Democratic supporters in Congress took on the task of creating a set of information technologies that has to interconnect with the I.R.S.; the Departments of Labor, Treasury, Veterans Affairs, and Homeland Security; the Social Security Administration; state governments; insurers; employers; hospitals; and practitioners in the private sector.
Robert Charette, president of the ITABHI Corporation — a tech firm specializing in risk management — describes the problems:
"HealthCare.gov is a huge system of systems and it's extremely difficult to manage these things even in the best of times. That's mostly because you have so many different interfaces with so many different assumptions controlling how the individual systems operate. And they're rarely built with enough flexibility to be used by lots of other systems. If you take a look at the IRS systems, the Department of Homeland Security systems, or any of the other ones we're talking about, they were never created to be connected to something like HealthCare.gov."
The seven million people officials initially estimated would sign up for the Obamacare insurance exchanges this year are putting their well-being and that of their families in the hands of government bureaucracies armed with demonstrably inadequate technological expertise.
The chaos surrounding efforts to activate HealthCare.gov reinforces a key conservative meme: that whatever the test is, government will fail it. Insofar as voters experience their interaction with government as frustrating and unreliable, the brunt of political damage will hit Democrats, both as the party of government and as the party of Obamacare.
Cumulatively, recent developments surrounding the rollout of Obamacare strengthen the most damaging conservative portrayals of liberalism and of big government – that on one hand government is too much a part of our lives, too invasive, too big, too scary, too regulatory, too in your face, and on the other hand it is incompetent, bureaucratic and expropriatory.
In addition, the Affordable Care Act can be construed as a transfer of benefits from Medicare, which serves an overwhelmingly white population of the elderly – 77 percent of recipients are white — to Obamacare, which will serve a population that is 54.7 percent minority. Over 10 years, the Affordable Care Act cuts $455 billion from the Medicare budget in order to help pay for Obamacare.
Those who think that a critical mass of white voters has moved past its resistance to programs shifting tax dollars and other resources from the middle class to poorer minorities merely need to look at the election of 2010, which demonstrated how readily this resistance can be used politically. The passage of the A.C.A. that year forced such issues to the fore, and Republicans swept the House and state houses across the country. The program's current difficulties have the clear potential to replay events of 2010 in 2014 and possibly 2016.
The dysfunctional A.C.A. portal is not the only liability for Obamacare.
In some states, insurance companies operating through new health care state exchanges are excluding key hospitals from coverage. In New Hampshire, for example, as Jonathan Weisman of the Times reported, there is one provider, Anthem Blue Cross, and it has excluded 10 of the state's 26 hospitals from participation in the company's coverage.
Responding to an email, Drew Altman, the president and C.E.O. of the Henry J. Kaiser Family Foundation, wrote of the A.C.A.:
"I think the bottom line here is that the 'winners' greatly outnumber the 'losers' in general and in the individual market in Obamacare, but the media and political math is different from the actual math. A significant minority of 'losers' or self-perceived losers and a few high profile bad outcomes (possibly NH) are more than enough to cause real political problems."
According to Robert J. Blendon, a professor at Harvard's School of Public Health, the New Hampshire type of problem is more endemic:
"This is the next big political story. The president promised people they could keep their doctor and implicitly their hospital. A number of state exchanges are like New Hampshire in that they are offering what are called narrow network plans. Some of these plans exclude coverage at children's hospitals as well, which means some parents with sick children will have to change their source of care. This too is not what was promised."
In the state of Washington, the Seattle Children's Hospital was initially left off the list of approved care providers by five of the seven insurers operating in Kings County through the state exchange, Healthplanfinder. The hospital was forced to sue state officials in order to gain eligibility.
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