Earlier this week, HILFY asked a good question:
how the Obamaites were able to create the ACA so cleverly that Trump’s vandals still have not been able to kill it?
I am reluctant to ascribe detailed and granular levels of intentionality to the ACA authors regarding anti-sabotage design.
At the highest levels, the political theory was that people would like the benefits of the ACA and provide a growing set of invested constituencies that would rally to the defense of the ACA if need be. And we have seen that at the highest levels. People now expect per-exisiting conditions to be covered and they expect guaranteed issue. Medicaid expansion has not been completely rolled back even in Kentucky despite a governor that campaigned on rolling it back. At the highest level of interest group politics, there is intentionality.
At lower levels, I don’t know. I really don’t. I think the key decision to make the US federal government the prime risk holder for individual market premium spikes was a key decision that has insulated the subsidized market has acted as a systemic counter-sabotage buffer but I don’t believe that decision was made for that purpose.
One of the key things that we need to remember is that the ACA as signed into law was a cobbled together contraption of various things that no one expected to be the final say on the issue.
I’m working with a great set of co-authors on a non-related piece that should be going out next week. I created the skeleton for the combined writing plan. The initial version had sections titled: “Explain the strangeness” and “Something awesome happens here” with bullet points and key references to explain the strange and the awesome. We then filled it in a bit more before handing it off to the publisher where they then did a nice edit with a bunch of questions. We then polished the piece, accepting all of the suggested edits and tweaked a few things that on a second read needed to be explained and had a nice long discussion on the implications of a comma. And then we sent the piece back to the publisher who will make it go live next week.
The ACA as signed in March 2010 was past the skeleton stage. It was not the final, finished, polished product of a regular process. The House bill passed with the belief that a Senate bill will also pass where the final details and polishing would happen in a conference committee. That did not happen due to the election of Scott Brown (R-MA) as the Senate GOP caucus promised to filibuster the appointment of conference committee members. So we got the rough draft Senate bill that passed 60-40 on Christmas Eve as the ACA.
If Democrats in 2009 were trying to repeal proof the bill, they would have extended subsidies to everyone, they would have insisted on a single national risk pool instead of state based risk pools and they would have enriched subsidies so that someone making $100,000 would be paying $200-$300 a month in out of pocket premiums for a $1,500 deductible plan.
The decision to make the federal government the partial risk holder for premium increases has been a major shock absorber over the past two years but I don’t know how much intentionality can be attributed past that decision?