Nothing that President Obama has said this week about the litany of technology problems facing his signature health care law matters. All that matters is whether those problems get fixed in short order.
How soon they have to be fixed is a subject of some debate, but former Obama health care advisor Ezekiel J. Emanuel (brother of Chicago mayor and former Obama chief of staff Rahm) has set the date at Thanksgiving.
By that time, if individuals cannot easily sign up for insurance on Healthcare.gov and the system cannot send reliable data to insurers, there are no good options for Obama.
Here are five possible fixes that have been suggested.
1) Don’t change anything. In this option, Obama would simply let the remaining parts of the law that haven’t already been delayed proceed on schedule.
The problem is that as currently conceived, individuals only have until Dec. 15 to apply for coverage that starts on Jan. 1, 2014.
If the system is still buggy come Thanksgiving, those likeliest to endure the arduous enrollment process are the sickest uninsured Americans, while young and healthy Americans are most likely to give up.
Come Jan. 1, this would be a nightmare for insurers. New beneficiaries with the highest medical costs will start seeking care and filing claims, and insurers won’t have the flood of premium revenue from healthier beneficiaries they were expecting to offset the costs.
Obamacare’s exchanges were expected to cover 7 million people next year and the administration had said that around 40 percent had to be young and healthy for the system to be viable.
Letting the status quo persist would also lead to a furious backlash against the individual mandate, which is already the most unpopular provision in the health care law.
It’s bad enough to force individuals to purchase insurance under the threat of a penalty, but how can you penalize Americans for failing to purchase a product they can’t access as promised?
2) Delay the individual mandate. On top of the incredible political embarrassment that would come from delaying a provision the Obama administration spent years defending in federal court, policy-wise, this would only exacerbate the problem mentioned above.
If Americans aren't penalized for failing to purchase insurance, the young and healthy ones will have even less incentive to buy it.
Insurers, who agreed to take on individuals with pre-existing conditions in concert with an individual mandate, would no doubt have something to say about this.
If Obama bypasses Congress to impose this delay, perhaps injured insurers could craft a legal challenge. Heck, they could even borrow the Obama administration’s own briefs about how inextricably linked the individual mandate is to the greater regulatory scheme of the law.
3) Partial delay of the individual mandate. Under this idea, the mandate’s penalties would be delayed, but only in the states where residents can’t easily access an exchange.
The problem is that it would still cause the same problems mentioned above for insurers in the states without the mandate.
It would also raise issues of fairness (and perhaps create legal problems) if the federal government imposed taxes on residents of some states but not others.
4) Extend open enrollment. Though the White House has emphasized that the enrollment period extends until March 31, the penalty for not purchasing insurance would hit people after Feb. 15 — including those who purchase insurance after that date.
So even if the enrollment period is extended past March 31, it may not pull in that many more customers because those who haven't purchased by that point would have to choose to pay premiums on top of the penalty.
It's also important to keep in mind why the time to enroll is limited. It seems counterintuitive at first. Wouldn't insurers want individuals to be able to buy their product all year round?
The problem is that if there were no such limitation, then healthy people — knowing insurers could never legally deny them coverage — could simply pay the fine and only purchase insurance if they became sick or injured.
How do you think the car insurance business would work if people could sign up for coverage after they were involved in an accident?
Obviously, there’s a difference when extending open enrollment in the first year of the program’s operation, but for this scheme to work, it’s also important to instill in younger Americans a sense of urgency to buying insurance by setting a hard deadline and sticking with it.
5) Delay the exchanges for a year, along with the requirement that insurers cover those with pre-existing conditions. This action would solve the problems facing insurers because they would no longer be forced to take on the sickest patients on Jan. 1.
But it would also create a public relations nightmare for the administration. Beyond earning the mockery of Republicans, Obama would have to explain to Americans who already endured the process of signing up for insurance — including those with pre-existing conditions — that they won’t be insured on Jan.1 after all.
There are, no doubt, other possible options. But none of them are easy. And all of them reinforce the fact that Obama really, really needs these tech problems to be fixed — and soon.