Assessing the Exchanges
...Meanwhile, the back-end communication between the exchanges and the insurers has been terrible, as is increasingly being reported. The extent of these problems has also been a surprise to CMS, and here too an increase in volume if the user interface issues are solved could lead to huge problems that would be very difficult to correct. CMS officials and the large insurers thought at first that the garbled data being automatically sent to insurers must be a function of some very simple problems of format incompatibility between the government and insurer systems, but that now seems not to be the case, and the problem appears to be deeper and harder to resolve. It is a very high priority problem, because the system will not be able to function if the insurers cannot have some confidence about the data they receive. At this point, insurers are trying to work through the data manually, because the volume of enrollments is very, very low. But again, if that changes, this could quickly become impossible.

In a couple of ways, then, the severe user-interface problems at the front end of the federal exchange has actually had some advantages from CMS’s point of view, because by keeping enrollment volume low it has kept some other huge problems from becoming instantly uncontrollable. ...

...One key worry is based on the fact that what they’re facing is not a situation where it is impossible to buy coverage but one where it is possible but very difficult to buy coverage. That’s much worse from their point of view, because it means that only highly motivated consumers are getting coverage. People who are highly motivated to get coverage in a community-rated insurance system are very likely to be in bad health. The healthy young man who sees an ad for his state exchange during a baseball game and loads up the site to get coverage—the dream consumer so essential to the design of the exchange system—will not keep trying 25 times over a week if the site is not working. The person with high health costs and no insurance will. The exchange system is designed to enable that sick person to get coverage, of course, but it can only do that if the healthy person does too. The insurers don’t yet have a clear overall sense of the risk profile of the people who are signing up, but the circumstantial evidence they have is very distressing to them. The danger of a rapid adverse selection spiral is much more serious than they believed possible this summer. They would love it if the administration could shut down the exchange system, at least the federal one, until the interface problems can be addressed. But they know this is impossible. ...

...An extension of the enrollment period for coverage, now set to end on March 31, seems to be almost taken for granted. A delay of the individual mandate penalty—which effectively begins in the middle of February—is not thought to be a crazy idea (though the people I spoke with said they have not seen internal preparations for such a move at this point).

The nightmare scenarios, the “unthinkable options,” involve larger moves than that—like putting enrollment on hold or re-starting the exchange system from scratch at some point. No one seems to know how this could work or what it would mean, but everyone involved is contending with a far worse set of circumstances than they were prepared for. This is a major disaster from their point of view, not a set of glitches, and they simply do not know how long it will take to fix. They dearly want to see progress day by day, but they are generally not seeing it. ...

...For me, and for other critics of Obamacare, the problem with the law was never about these technical matters. I didn’t think the system wouldn’t work because the government couldn’t build a website, but because the basic health economics involved is deeply misguided and would take the (badly inadequate) American health-financing system in the wrong direction. So these problems only seem like a prelude to other, larger problems. But Obamacare was also always going to be a test of the sheer capacity of the administrative state to actually do what it claims the authority and ability to do. At this point, it looks as though we may be witnessing a failure of the administrative state on a level unimagined even by its staunchest critics. We may be. But we’ll have to see.

Doctors prepare for Obamacare race to the bottom
...New York doctors are feeling queasy about ObamaCare — and many won’t participate in the new national insurance program because they fear they’ll go broke, The Post has learned.

“ObamaCare is going to send me more patients to see and then cut the payments to provide the care — that’s what’s going to happen,” predicted Donald Moore, a primary-care doctor in Prospect Heights, Brooklyn. “I will not accept it.”

Moore claims that President Obama made a big mistake by requiring uninsured residents to obtain medical coverage from for-profit insurers through the ObamaCare health exchanges instead of through public health programs like Medicaid.

Under tremendous pressure to keep costs down and profits up, Moore said he’s concerned that commercial insurers will pay doctors less for patient visits and services than either Medicaid or Medicare....