The Obamacare Plot Twist

Thanks to health reform, insurance premiums are plummeting in New York. That's some desperately needed good news for the bill's supporters.


For months, we've been told that the impending implementation of the Affordable Care Act (aka Obamacare) will lead to soaring healthcare costs and more expensive premiums. That narrative has taken hold, even for those who otherwise support the suite of reforms. And that's why the recent front-page article in the New York Times, reporting that premiums in New York State may actually fall 50 percent or more, came as such a surprise.

Only a few weeks prior, the Wall Street Journal announced that "Healthy consumers could see insurance rates double or even triple when they look for individual coverage under the federal health law later this year." Their analysis did acknowledge that ailing individuals could see rates fall, but the driving point was one that has been made ad infinitum by critics of the reforms: costs will soar.

So entrenched is that view that the Republican-controlled House of Representatives continues its quixotic quest to repeal the bill, and voted this week for the 38th and 39th times to repeal parts of the bill, including the "employer mandate" that the Obama administration has already decided to delay.Paul Ryan said about the latest vote: "This law needlessly raises healthcare costs. And this law will cause millions of people to lose the health insurance that they have, that they want to keep."

The debate distills to this: Can a bill that depends on an uneasy blend of free-market incentives and government regulation succeed in providing universal access to healthcare at a reasonable cost? The premise of the act in the first place was that a system of healthcare exchanges would encourage competition and keep prices moderate even as the pool of insured people expanded.

But that assumes that states implement it in good faith. The staunch opposition of Republicans has meant that many states with little regulation of insurance companies or healthcare are delaying or actively resisting many aspects of the bill. What's clear is that opposing the bill is a good strategy if you want the reforms to fail. The success of the legislation depends on the cooperation of state governments, insurance companies and federal regulators. That is hardly unusual, but the complexity of the reforms make it all the more imperative.

Yet the divergences over the bill and its consequences mask a rather severe rift between federal actions, state conviction and popular opinion. Despite laws passing at the federal level, the reality is that the United States remains a federal system that requires vast efforts of compliance by states and by individuals. One of the great gripes of state-level politicians is that Washington is forever passing "unfunded mandates" and assorted vague and complex laws, and then leaving it to states to pay for and figure out the implementation. The Affordable Care Act is Exhibit A for these tensions.

Yet for the American system to work, some level of compliance and trust are essential. That is true for paying taxes, and it's true for healthcare reform. There is no way the government could actively force every single person to pay taxes without creating a coercive police state. And healthcare reform will not work unless multiple segments of society work jointly and cooperatively. Even the vaunted aspects of the bill that encourage competition require some level of cooperation. Various insurance companies and state agencies have to hash out the details of the proposed exchanges for the currently uninsured and provide alternatives for those currently insured under different plans.

In short, the bill requires what Silicon Valley firms have called "coopetition," which acknowledges the tensions and competition inherent in various enterprises but recognizes that there are joint needs that demand collective action. Coopetition as applied to healthcare implementation would mean different states would have thicker or thinner regulatory regimes, and more or less competitive pricing of insurance, but that all would make a good faith efforts to implement healthcare exchanges and honor the federal mandates for universal coverage.

Yet opponents have been set against the act. Unlike other examples of intransigence in the face of a national bill, obstructing the Affordable Care Act might fatally undermine it. Southern opposition to the Civil Rights Act of 1964 and the Voting Right Act of 1965 triggered federal responses that forced compliance, but there the moral issue was widely settled, and there were clear mechanism to force compliance. You can't do that with the Affordable Care Act. There is no scenario where Obama could call out the national guards to force states to open functional healthcare exchanges.

That's why the news from New York is so potent. The primary fuel against the act is that it will expand the scope of government at the expense of prosperity and good healthcare. That is why there have been so many stories of businesses threatening to lay off workers if the bill is implemented, and so many tales of soaring costs directly harming already stretched individuals whose incomes have stagnated. But if the bill actually lowers costs and delivers care that is at worst not much different than now, then the opposition begins to fracture.

The most likely scenario, of course, is that states that work with the bill will find a way to contain costs and perhaps lower premiums for individuals and for companies. State governments that oppose the bill might succeed in driving costs up. That could in turn keep the ideological fires nicely tended. Opponents and supporters can claim victory, and blame negative outcomes on the other.

That said, if even a handful of larger states can demonstrate lower costs and expanded care, that will be a body blow to opponents who have relentlessly promulgated the story that expenses will soar and the quality of care will plummet. Ultimately, almost everyone wants universal care and good care, even as there are adamant conflicts over how to provide those. Others states could well look at how pricing in New York unfolds and then demand the same for themselves.

If this much-reviled bill proves to work for tens of millions in select states, it will change the current narrative dramatically. It will demonstrate that collective action is not just desirable for optimal collective outcomes; it is essential. Fight all you want to prevent laws you dislike from passing; work all you wish to amend laws that have passed; but once those laws exist and have been validated, work together to implement them. Sounds oddly naïve in today's jaded world, but it's the only way forward.

"The Edgy Optimist" column is initially published at, an Atlantic partner site.