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Remember Bush’s Medicaid Expansion? Same Problems with Obamacare!

52524b892476c.preview-300Ocean Springs    News analysts are already noticing some shifts in the dogmatically ideological opposition of the Republicans to Obamacare as they come to grip with the fact that despite a plethora of problems, two million people are likely to start the new year, 2014, enrolled under the Affordable Care Act or Obamacare with millions more to come.   These numbers are certainly beneath expectations and predictions but still start to represent a growing constituency that is not going to be happy and will be quick to defend against losing these new entitlements.  The Republicans are going to have to learn the lessons taught about new social programs since Roosevelt that once on, there’s no going backwards.

Similarly, I found it interesting to read Richard Thaler and Cass Sunstein’s book, Nudge:  Improving Decisions about Health, Wealth, and Happiness, especially the chapter which looked at the government’s problems during the George W. Bush Administration in expanding drug coverage for Americans under Medicaid Part D.  Wow, talk about some same-same in the mess and mayhem that we’ve now so quickly forgotten.

One of the things Thaler and Sunstein found that is definitely true of Obamacare is the fact that “the more choices you give people, the more help you need to provide.”  Amen!  With four levels of benefits and over 30 company plans on offer in Texas for example, even with websites humming, these are just plain hard choices for families, especially those who have been previously uninsured and are therefore unsophisticated about the various options.  Furthermore, as they reminded about Medicaid Part D, “…many people are still not enrolled in the program…four million uncovered Americans is a large number.”

Part of what the authors argue is that when people don’t know what choices to make or are confused by default they make no choices whatsoever.  With this experience then and now with Obamacare, it seems even clearer that they are correct that it would have been better to enroll eligible people by default and let them elect to move to other plans or decide to continue to be uninsured than scale the complex maze to coverage.

Thaler and Sunstein were also very critical of random assignments, similar to what some states like Arkansas have adopted for their Medicaid expansion programs in the absence of choices, because random assignment didn’t work for Plan D because it mismatched people’s drug needs insurance policies that were unable to handle it.  Random assignment, they argue correctly, is more about protecting each company’s market share than fitting the consumer’s needs.  Better for people to have what they refer to as a “choice architecture” with a clear path of decisions for the consumer so that a better informed choice can be made.  As they state flatly, “Random default plan assignment is a terrible idea.  If a poor person is assigned to a bad plan and does not switch, her drug bills may rise, or she may decide to stop taking an expensive drug, as some already have.”  They give an example of a Massachusetts company, Experion Systems, that developed a better on-line “drug plan assistant” tool to “guide better decision making” and was much more user friendly that the government’s website.

Sound like deja vu all over again?  And, these are self-styled “libertarian” economists not some more ivy-covered red-heads, so to speak!

We could have learned from the Bush Administration, but unfortunately even the Republicans that were part of that play seem so committed to fighting their losing Pyrrhic fight against Obamacare that they didn’t help us keep from stumbling once again and making the same mistakes this time around.

We gotta learn!