Q&A: Implementing Obamacare

Feb 25, 2014
B. Rose Huber
Woodrow Wilson School

On Feb. 27, a panel of leading health care experts will gather at the Woodrow Wilson School for a panel discussion, "Implementing the Affordable Care Act."

To preview the event, we sat down with Keith Wailoo, vice dean of the Wilson School and the Townsend Martin Professor of History and Public Affairs, to determine – from a historical perspective – how the ACA rollout compares to past health care policy rollouts.  

Q: How can our past lessons (ex. Medicaid/Medicare rollouts) inform our present situation with the ACA rollout?  

Wailoo: For all the controversy surrounding the ACA rollout over the past months (from the broken website to the slow pace of enrollment), there are some striking resemblances to previous cases of implementing big new programs. The Social Security rollout in the 1930s was a disaster. The Medicare rollout after 1965 was administratively much smoother, but Medicaid took time – some states were so cautious about signing on that in 1969 twelve states hadn't joined – including New Jersey. It wasn't until 1982 (18 years after the law passed) that Arizona became the final state to sign on the Medicaid. Historically speaking, the ACA rollout has been bad – but neither the pace nor the controversy nor the federal-state dance of coverage should be too surprising.   

Q: Why has this rollout, in particular, been so rocky?

Wailoo: This ACA rollout is incredibly diffuse – with some states setting up their own exchanges, some allowing the federal government to set up the exchanges and other states (about 22 in all) opting out of Medicaid expansion. This scattered implementation makes it an inherently uneven, rocky and politically fractious process. Some states like Kentucky, because of its relatively small population and strong-willed, supportive Democratic governor, have seen surprisingly smooth rollouts with high-enrollment numbers and considerable enthusiasm for the law. Other states, like Arkansas, are still mired in controversy. If the long history of Medicaid is any guide, my strong sense is that these wide disparities will continue for months, if not years.

Q: How has health care policy evolved in the past decade? 

Wailoo: What's most surprising about the evolution of health care policy is that it has actually evolved (that is, that access to health care has expanded), despite strong forces against. It was only 20 years ago that the Clinton health plan was defeated, prompting the president to admit that "the era of big government is over." Since then we've had the creation of a robust Children's Health Insurance program (supported by Republican Congress and passed in 1997 in Clinton's second term), an expansive prescription drug benefit in Medicare (passed by Republican-controlled Senate and House,and signed by George W. Bush in 2003) and the ACA passage in 2010 under Democratic controlled House and Senate, signed by Barack Obama. It seems that ideology and party affiliation aside - and despite lingering fiscal concerns about big government - the trend tilts toward increasing access.