Wednesday, April 10, 2013

PPACA - Get Ready For the Incompetence

Last week I attended a lecture and subsequent discussion of the Patient Protection and Affordable Care Act at the Goldman School of Public Policy at UCB, my alma mater.  The lecturer was Theda Skocpol, a  liberal political scientist enthusiast and booster from Harvard.  (Don't read her book, it's mainly boosterism.)  One question in the discussion remained unanswered -- why has the Obama Administration and the Democratic Party not done better publicity for the virtues of PPACA? 

The opposition has done very well, by contrast.  It's the media's fault!  Of course, it's always the media.  But one audience participant said, hey, I used to be a political reporter, and I don't think it's the media's fault at all.  So the question was just left to lie there.

I wanted to put in my opinion - big surprise there - but I had other fish to fry as I commented on the lack of understanding of the professional political forces.  Skocpol and others lumped doctors and hospitals together, and there was collective derision of the high salaries doctors earned, and derision when a primary care doctor of one of the discussants told him that it was tough to attract doctors to her group because they could only offer $145K as an initial salary.  Collective derision -- who do these people think they are?  Why should they earn more thus us academics? 

Another discussant compared the forces around Medicare and those around PPACA.  It was left to yours truly to point out the stark differences between then and now.  The AMA is now shattered, and mattered little in PPACA.  Medicine has been corporatized.  Hospitals matter much more than doctors.  If there is a bill for a procedure in a hospital, the doctor will bill $500, the hospital will bill $15,500 - at least.  The professional specialty societies and academic medical centers matter more than the AMA.  I was supported in this view by discussant Steve Shortell, Dean of the School of Public Health, but it was amazing to me that Skocpol seemed not to be aware of this.

But back to the point - why did support for PPACA not come from the Administration and the Democratic Party the way one would expect?  Where was the bully pulpit?  My answer is -- did anyone ever hear of incompetence?  The President's bench is thin.  Where are the health heavyweights?  Where was the aggression necessary for the 2010 elections?  Nowhere, because they aides suck, and Obama himself doesn't know details - he is rather health illiterate.  Sibelius seems not to know much, and is not persuasive - she is a talking points person.  Obama is great at big picture rhetoric, but not in nitty gritty.  They just don't have it.

This will be a problem as we go down the road - incompetence in HHS will make the going very rough.  Today comes a report from Kaiser Health News that only a pittance is budgeted for enrolling people in the Health Insurance Exchanges.  Healthy people won't get the coverage, and the finances will suffer.  Why?  KISS.  It's just incompetence.  Deadlines keep slipping, the type of insurance will continue to emphasize high deductibles, I predict, and Universal Crappy Health Insurance (UCHI) will reign.  When I brought this up in my brief remarks, Skocpol replied that she is too old not to accept the imperfect. 

Jesus, what a cheerleader.  For a smart lady, she is too willing to overlook incompetence, in my view.  But maybe I'm wrong, and it is all just the necessary first steps.  Maybe the compromises were not incompetence, but just necessary.  I only worry that poor first steps can lead to a long ramp up.  Like, how long does it take teams to overtake a history of bad draft picks?  Answer: a long time.

Budd Shenkin

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