The 2014 Myth

For some reason, smart people continue to repeat a misconception, and smart people continue to quote smart people repeating that misconception. The reason the health reform law's biggest pieces--the expansion of Medicaid and the launching of health insurance exchanges where people will be able to choose from a variety of private health insurance plans--don't go into effect until 2014, the misconception goes, is that a trick was played to make the numbers work out right. If only that trick hadn't been played, the law would already be fully in effect and in significantly less danger of being torpedoed after the next election.

The WashPo's usually great Sarak Kliff quotes the usually impressive Paul Starr:

Paul Starr makes a smart point in his recent Washington Post op-ed on the health reform law. The law’s unpopularity, he argues, has a lot to do with the fact that it had to be constrained to get a good score from the Congressional Budget Office:

Primarily to ensure that the Congressional Budget Office would “score” the legislation as reducing the deficit, Obama agreed to delay implementation of the major provisions of the law until January 2014, nearly four years after the bill passed. And contrary to his position during the 2008 campaign, the president also agreed to an individual mandate — again, partly to keep down the program’s cost — even though the mandate predictably became the law’s most unpopular provision and the focus of legal and political challenges.

These concessions have had opposite effects on the emotional commitments in the two parties. While opposition to the mandate has become a rallying point for Republicans, the long delay in implementing reforms has left many Democrats discouraged and uncertain about the law’s benefits. The four-year timetable also undercuts any possible political gain from the reforms; the president will have little to show by the 2012 election and little chance of clearing up the confusion and anxieties about the law.

The reality is that those big pieces of the reform law are tough. They're being built state-by-state and are subject to myriad local political hurdles, not least because the Republicans did especially well at the state level in the 2010 elections. But even putting aside the political constraints, the technical and policy feats needed to make this work are substantial. Even in those states that want to make this work and are moving full steam ahead to implement the law, the challenges are very real and the dangers of missing the 2014 deadline loom.

That's part of the reason the federal government is bending over backwards to be as collaborative and flexible as possible. For example, the law provides that states that don't set up their own health insurance exchanges get one set up and operated by the federal government. But through the rulemaking process, the folks at the Department of Health and Human Services are proposing a few more shades of gray--varying degrees of federal control to help states stand up their own exchanges by leaning on federal support for certain key features. States can then conceivably retain autonomy over their exchanges, yet not shoulder the technical and operational burdens of making an exchange work all by themselves.

The point here is that the suggestion that health reform could already be implemented under some scenario is simply wishful thinking. This is hard, uncharted territory: minus pieces of the Massachusetts experiment, no one has ever done anything like this. That's why it's going to work. But states were always going to need time to make it happen.

And guns. Lots of guns.