The problem with solutions is that few of them tend to be perfect, even if they act in a mostly benign manner. Actions produce reactions, a principle as true in politics as it is in physics, and those tend to multiply when solutions increase in complexity.
The nature of these unintended consequences changes dramatically when complex “solutions” turn out to be poorly designed and incompetently administered.
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The rollout of the Affordable Care Act has provided many real-world examples of this, but perhaps none so “unintended” as the consequences discovered by the Seattle Times this weekend. Carol Ostrom, The Times’ health reporter, told the story of 62-year-old newlyweds Sofia Prins and Gary Balhorn, who weren’t exactly the models of wild, starry-eyed romantics.
Their nuptials were motivated by a stronger desire to keep their house out of the hands of the federal government, thanks to a little-known key provision of Obamacare. Their meager incomes made them eligible for a federally subsidized health plan, and their assets would be protected.
Does Obamacare actually allow the federal government to seize homes and other assets? Before answering that question, let’s go back to what supposedly motivated the Obama administration and Democrats to pass the ACA in the first place.
For years, Democrats had demanded federal action to address the problem of Americans without health insurance coverage. Estimates of this population went from 14 million to 40 million during the debate in 2009-10 over the scope of the crisis and potential solutions for it.
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While those numbers sound large, a Gallup poll in late 2009 put them in better perspective, noting that 85 percent of American adults had health insurance, 87 percent of whom were satisfied with their coverage, and 61 percent satisfied with the costs. Even among the uninsured, half were satisfied with their situation, although only 27 percent expressed satisfaction about their costs for health care.
Instead of designing a solution that focused on the half of the 15 percent who needed better options and leaving everyone else alone, Barack Obama and his fellow Democrats on Capitol Hill insisted on imposing an overhaul of the entire health-insurance industry. This includes, crucially, an unprecedented individual mandate to carry health-insurance coverage. The ACA contains a highly-complex series of subsidies that help working-class Americans pay the now-skyrocketing premiums caused by coverage mandates on insurers, but only down to a certain income level.
Below that point, Americans who do not have employer-based coverage have to accept Medicaid coverage in order to comply with the Obamacare individual mandate, or pay full price for the skyrocketing premiums from private-sector insurers.
People often confuse Medicaid with Medicare, but there is a critical difference between the two programs. Medicare eligibility derives from Social Security contributions, and is a true “entitlement” program. Theoretically, coverage comes as part of the funds paid into the system, although in reality the federal government has to borrow billions of dollars to cover the costs.
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Medicaid, on the other hand, is a state-based and federally-subsidized welfare program, one that employs means-testing – which includes ownership of assets as well as income levels. Medicaid programs include conditions that put recipients’ assets remaining after death at risk for seizure to reimburse taxpayers who footed the bill for the recipient’s health care during his/her lifetime.
This was done to prevent fraud, to ensure that limited resources went to the truly needy, and to recapture resources to cover future costs. Until now, though, Medicaid was a voluntary program, and the vast majority of people who entered into it had few assets to risk by signing up.
Here’s where the law of unintended consequences comes into Obamacare. Thanks to the exchange programming, consumers are getting enrolled in Medicaid whether they understand what that means or not, and in much greater numbers than before. (In the first month, nearly 90 percent of all the enrollees in the federal and state exchanges were Medicaid applicants.)
Unless they look at the fine print in the paperwork in Washington and other states with similar asset-forfeiture regulations, any assets they own will not pass to their heirs but to the state instead.
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Prins and Balhorn are hardly alone in Washington. Adults between the ages of 50-64 account for 18 percent of the enrollments in the state’s Apple Health Medicaid program, and the seizure regulations apply in their cases for those 55 and older. The state exchange uses only income levels to means-test Washington applicants for the program, which means most of them will have no idea that their assets are at risk until it’s too late.
“People will think this is wonderful, this is free insurance,” Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons, said in an interview. “They don’t realize it’s really a loan, and is secured by any property they have.”
Related: Insured Americans Blame Obamacare for Higher Premiums
That’s one of the problems of Obamacare itself – the perception that it’s a free lunch. Even those who do qualify for subsidies get that only through the collection of a myriad of taxes imposed by Obamacare. Those taxes apply to employers, insurers, and medical-device manufacturers, which drive up the costs for consumers and workers in indirect ways. It’s a shell game--not a reform that actually drives costs down. Instead Obamacare only masks price increases through dishonest opacity.
The problem here is the arrogance of the solution itself. Had the Obama administration focused on just those who could not get coverage because of income or pre-existing conditions, they could have expanded Medicaid in an intelligent manner while protecting existing assets, without disrupting the rest of the market.
That might still have been controversial and would not have been cost-free by any means, but it would not have fatally undermined a system that worked for 85 percent of Americans and misled many of the rest into risking their estates without any warning that government would strip their heirs of family homes.
Targeted and modest solutions minimize unintended consequences, and allow for more speed and efficiency when they do arise. Obamacare will serve for decades as the cautionary tale when arrogance rules over modesty and common sense.
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