Republicans are having a bad month, but they should cheer up. Sure, conservative lawmakers have flamed out in dozens of attempts to defund, delay, repeal and pick off pieces of the Affordable Care Act, and the GOP has taken the brunt of voter outrage over the shutdown precipitated by that crusade. Yet with a big assist from its governors, the party has already done damage to Obamacare in numerous, possibly profound ways.
Let's start with the disastrous launch of the behemoth federal insurance exchange run by the Health and Human Services Department. Yes, Republicans managed to divert attention from that to their own comedy of errors on Capitol Hill. But don't forget why the federal exchange, healthcare.gov, is so gigantic. It's because just 16 states and the District of Columbia created or plan to create their own marketplaces. By contrast, almost all of the nation's 30 Republican governors took a pass on setting up exchanges for their own states, punting that task to the feds. That along with other tactics and decisions amounts to what you might call the GOP Effect—damage that's indirect, often uncoordinated, and possibly at times unintentional, but potent all the same.
For instance, some of the initial problems on the federal exchange were due to heavy traffic. It would not have been as much of a bottleneck had more governors created individual state exchanges. More serious and continuing problems are due to misjudgments and shortcomings embedded in the federal website itself, and the worst may be yet to come.
Micah Sifry, cofounder of the website techpresident.com, says the companies that end up winning big federal contracts—for instance, CGI Federal and major defense contractors—"are not known for their innovative or up-to-date technology. They are known for their ability to win contracts." Political decisions by the Obama Administration, such as requiring consumers to determine their subsidy eligibility before they can shop and see rates, also may be factors in the online mess.
The 16 states that built their own sites have used a variety of contractors and many of their marketplaces have launched more smoothly than the federal healthcare.gov. The bottom line is that the pressure on the federal exchange would have been far less and its design flaws would have affected many fewer people had, say, 20 more states set up their own exchanges using a variety of contractors and approaches.
There's also a toll that comes from having to set up systems to run or help run three dozen exchanges. That took time that might have been spent preparing for a smoother opening. "The federal exchange has to interact with health plans that are submitting bids in 36 states, and also has to work out data agreements with how to handle information flow with 36 different Medicaid agencies, and they've had to work out insurance oversight with 36 state insurance departments," says Alan Weil, executive director of the National Academy for State Health Policy. "It's a huge workload that competes for resources with building the exchange functionality."