One of the major problems I have with fixing the Affordable Care Act is that we are being led by a bunch of morons. Bob Laszewski said “about everybody believed about all of the states would establish their own exchanges” and what do most of the states do? We go from every state wants to set up an exchange to almost no state wants to set up their exchange. Doesn’t anyone see this as a major problem with making health care simpler, better, and more cost efficient? So these same folks have now focused their attention to preserving subsidies rather than making our health care system work better. Unfortunately preserving subsidies turned healthcare.gov into an unnecessarily complex, cost shifting system that requires an unknown number of IRS minions to enforce. Okay, we screwed up. Now is the time to fix it before we turn our health care system into a VA system on steroids. What would it take to make state exchanges work? State exchanges would require a simpler system that minimized development and ongoing costs. Fortunately for us states have limited budgets so complicated systems that do not add value to the customer is not an option. Streamlining or replacing the subsidy system with a simpler cost shifting system that could be implemented in a state exchange without much difficulty would be the first priority. It sounds simple. Instead we seem to be locked into a complex national health exchange we did not want and will most likely fail.

My own observation, having closely watched the original Obamacare Congressional debate, is that this issue never came up because about everybody believed about all of the states would establish their own exchange. I think it is fair to say about everyone also believed a few states would not establish their own exchanges. Smaller states, for example, might opt out because they just didn’t have the scale needed to make the program work. I don’t recall a single member of Congress, Republican or Democrat, who believed that if this happened those states would lose their subsidies.

Until the Progressives are willing to perform a seppuku on the Affordable Care Act, health care reform will be stuck on stupid. I hate to be brutally honest but there is not much left to gut when you look at all of parts of the Affordable Care Act that have been delayed. Since the Democrats wrote the bill by themselves, they own the Affordable Care Act problems and gutting the bill is preferable over a long prolonged death.  When the smarter half of the Democratic party drew that imaginary line in the sand, they were of the opinion that health care reform cannot not succeed unless we get a majority of the states to set up health exchanges. For both political and governing reasons this form of co-operative federalism depends on states being willing  participants. Without a majority of the states participating via state exchanges the backup plan of a federal exchange would transform the law  into a plain old federal power grab built on the shifting sands of administrative law rulings. This smarter half probably viewed the federal exchange scenario as a recipe for political and governmental disaster and extremely hazardous to their re-election. Unfortunately they were proven right. The healthcare.gov roll-out was a grim reminder that our federal bureaucrats are not as competent as we thought and if you want to create a really big problem, the first step is to make it a federal program. The problem we are faced with now is that we are ignoring our past mistakes. Ms. Greenhouse in her article, “By Any Means Necessary”, seems to think that we can safely ignore the legal problems and the lack of political consensus. In a way she is advocating the idea that laws do not matter if it impedes the society’s greater goal, health care reform. This is what I call the “even a blind squirrel finds a nut once in a while” management style or otherwise known as management by accident. This is the evil twin of the more successful management style employed by businesses called management by objective. The management by accident approach is based on the hope that if we have enough people stumbling around trying to fix things they think might be wrong then we will eventually fix all of the Affordable Care problems regardless of how badly the law was written or administered. All we need is money, people, and lots of patience with government failures. This might be an acceptable solution in the federal bureaucratic universe but it reminds me why the  healthcare.gov roll-out was such a miserable failure and why my insurance premium continues to go up despite promises otherwise. It should be amusing to see who gets the blame if the number of uninsured returns to historical norms this Fall. This is the Progressive’s proudest Affordable Care Act achievement.  Will we be reminded once again that the Affordable Care Act was a health reform in name only? If this is the Progressive idea of health care reform then would someone  “wake me when it’s over.”