12 ms·

For context, the original intention was that states would run their own exchanges, only if they refused would residents of the state use the federal exchange.

• mlinhares 3y ago
  If I was running a state agency and the federal government told me I could just use their system instead of spending my own money I would definitely take on the federal government instead of paying for it. Sometimes the whole "states are their own thing" here in the US goes way too far.
  • fastball 3y ago
    Really depends on if the federal-level system is better or not than what you have, no? Sometimes the stars align and the federal government builds a system that is actually nice to use. But sometimes the system is a steaming pile of shit.
    • tilne 3y ago
      It’s a public-facing IT system owned by some government agency in the United States. “Sometimes” is an understatement. (Though maybe this is a failure on my part to update my priors. I’ve noticed that recently some of the systems that led me to form this opinion in the past have become very functional, if not exactly pleasant to use.)
    • a_subsystem 3y ago
      What are some that are not steaming piles?
      • knowaveragejoe 3y ago
        There has been a massive effort to improve various federal websites(of which I believe there are hundreds of thousands). These folks have done some really impressive work on overhauling a lot of said systems: https://www.usds.gov/ https://www.usds.gov/
        • mlinhares 3y ago
          I must say I am SOMEWHAT happy with USCIS and IRS, which are the two ones I deal with the most, they actually resemble modern systems and not something made in the 90s.
      • ericbarrett 3y ago
        weather.gov
    • wolverine876 3y ago
      > Sometimes the stars align and the federal government builds a system that is actually nice to use. > But sometimes the system is a steaming pile of shit. I'm pretty sure I've seen the same outcomes in private business too. Just look at the history of Windows, as one of very many examples.
    • gumby 3y ago
      Your statement work if you take "federal" out. It is true in all domains.
  • ceejayoz 3y ago
    In many cases, it was ideological, not fiscal. States opting not to open their own exchange (grey): https://en.wikipedia.org/wiki/HealthCare.gov#/media/File:ACA_health_insurance_exchanges_by_state.svg https://en.wikipedia.org/wiki/HealthCare.gov#/media/File:ACA... States opting not to expand Medicaid (blue): https://upload.wikimedia.org/wikipedia/commons/4/47/Medicaid_expansion_map_of_US._Affordable_Care_Act.svg https://upload.wikimedia.org/wikipedia/commons/4/47/Medicaid... (The second chart had more blue at the time; opt-outs have gone from 26 down to 10 now.)
    • mlinhares 3y ago
      Such a stupid ideological take from these places, if they really wanted to tank the whole thing they should have built their own exchanges and make them suck just like some states (like Florida) make the unemployment system so insanely complicated many just don't even try to apply for it. I'm glad they're not smart enough to do that though and people were able to get healthcare through the federal exchange. I hope these bigots continue to be evil and dumb, if they get smart then we're really in for a bad time.
      • toolz 3y ago
        maybe if the centralized government gets smart we'll actually have a good time...as it stands our healthcare in the US is abysmal and neither political leaning has any right in name calling - both ideologies have failed miserably.
        • kaibee 3y ago
          > both ideologies have failed miserably. Y'know the ACA originally had a public option in the bill. Guess which side killed that? Why did we even need an ACA-with-private-insurance-companies anyway? The ACA was initially copy of what was implemented in Massachusetts by Mitt Romney. It's frustrating that Democrats had to compromise just to end up with a system that only somewhat better than what it replaced, and then get blamed for the result.
          • 3y ago
  • blastro 3y ago
    More states are moving towards the state based model as time goes on
    • gumby 3y ago
      This application is one that makes sense to run locally with the fed's implementation as a backstop and baseline (that rases the standard of minimally acceptable) -- and in this case bootstrap as well. California has a good system that is roughly standalone while NY has one (also good) that is integrated into other NY programs. Both fan out into a network of actual humans (mix of private and public sector) that help make it work for people who for whatever reason can't use the online service. It's hard for the feds to do something like that at scale -- for example to have it integrate into other lcal programs.
  • bee_rider 3y ago
    The state is lower-level and, as a result, more accountable to the people. It ought to have more incentive to not screw this sort of thing up. At least, I had much more faith in my state government (MA) to not half-ass this kind of thing.
    • galago 3y ago
      The ACA was largely based on the Massachusetts healthcare plan, so they had already successfully implemented much of this.
  • _ea1k 3y ago
    This often depends on how the program is funded. The state may be able to get money to run the system and if they are ok with becoming dependent on that, they might take it. See also, NEVI, where the government is spending billions of dollars to build chargers via a complicated system involving state managed programs. It was passed almost two years ago and hasn't deployed a single site.
  • liveoneggs 3y ago
    Would you also take federal money to expand medicaid coverage to the poor citizens of your state? If so you might not be qualified to be a republican governor. Wouldn't it be much better to hire your friends as IT consultants, make broken systems as confusing as possible, and continuously change the rules, and then starve the half-assed system of funding in an attempt to keep people from signing up for coverage at all? What makes this plan doubly republican-friendly is that all players are your donors and most victims are minorities.
    • fragmede 3y ago
      [flagged]
    • cscurmudgeon 3y ago
      [flagged]
      • deathanatos 3y ago
        … this is just whataboutism. I can disagree with Republican cronyism and the endless "let some private contractor do it poorly" when the Federal government could just do it directly, and poorly, but with less indirection. … I can also disagree with blue state's NIMBYism, "I got mine and screw you" attitudes towards housing, and work to promote things like better zoning laws, fairer tax legislation, better public transit, etc. at the same time. (Note: the parent edited the above comment to add the CNN article. At the time I replied, it was only the NYT link.)
        • cscurmudgeon 3y ago
          It is not whataboutism. It is pointing out outcomes in the other approaches may not be as good sounding as they are. You know how NIMBYism is done in California? It is usually along the lines of "We can't let developers profit!!" and "They are going to build luxury homes and not affordable homes!!".
          • 3y ago
  • dilyevsky 3y ago
    > If I was running a state agency and the federal government told me I could just use their system instead of spending my own money I would definitely take on the federal government instead of paying for it. That’s because you completely misunderstand how government bureaucrats think. You’re not paying for it - the taxpayers do
• sneak 3y ago
  The Nevada one is unusable; I am resultantly presently uninsured despite trying very hard and having successfully signed up last year. I have money and the desire to transact and I cannot. The system is a failure.
  • MajimasEyepatch 3y ago
    Well, for one thing, open enrollment starts on November 1, so you can't get an ACA plan anywhere until then without a qualifying life event. Also, if the website is broken, you should be able to call and talk to someone to get a plan. Not ideal but it's not like you're completely out of options.
    • sneak 3y ago
      If only I’d thought of that. The phone support just leads to a ticketing system that responds via the web app. You can’t log into the webapp from foreign IPs without locking out the account (which can only be unlocked via the phone number on file, which only supports US mobile numbers and not Google Voice). They don’t use email. If your autopay credit card expires, they cancel your policy without any notice but paper mail, which is insane in 2023. They won’t let you reinstate it, even if you backfill pay your unbilled months. It only works for people with a single US number who get their paper mail on a regular basis and never travel for long periods of time. I live in Europe half the year and the service is unusable. I long for an actual free market in this shit.
      • paulddraper 3y ago
        > without any notice but paper mail, which is insane in 2023 FWIW the IRS operates entirely over paper mail. (Not sure why, I suspect is that paper mail is more expensive for fraudsters.)
        • HWR_14 3y ago
          The IRS does not. You can pay the IRS via the web, for instance.
• mherdeg 3y ago
  I *swear* that a year or two into this whole thing there were a wave of articles about how individual state marketplaces were having insurers exit the state marketplace. The story which I am *sure* I read more than once said that an insurer found they were losing money on a small number of patients with very expensive treatment needs which drove up their costs so much that no one else wanted to buy their product at its new price. I went looking for articles about this recently and couldn't find them any more. Did I imagine this happening?
  • jxramos 3y ago
    Yah I recall hearing stories of that. I was in the individual market at this time shopping for bronze silver and gold plans and trying to make sense of it all. This was the era where the world of https://www.hhs.gov/healthcare/about-the-aca/pre-existing-conditions/index.html https://www.hhs.gov/healthcare/about-the-aca/pre-existing-co... entered the lexicon.
  • dragonwriter 3y ago
    I think a lot of this was related to the risk corridor payments insurers were entitlted to for 2014-2016 but which Congress simply refused to fund, resulting in a lawsuit that reached the Supreme Court in 2020 ruling that, yes, the payments had to be made.
    • ceejayoz 3y ago
      The loss of the individual mandate also probably plays a big role.
      • s1artibartfast 3y ago
        I imagine that would hurt the situation not help it. The individual mandate was intended and served more healthy individuals into the insurance pool.
        • dragonwriter 3y ago
• sproketboy 3y ago
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• jmyeet 3y ago
  Your comment about states running marketplaces reminded me of the ill-fated Clinton-era welfare "reform". This moved Federal funds to state block grants and states managing programs and eligibility (ie TANF) [1]. The result? The system became significantly less efficient in terms of how much of each Federal dollar resulted in aid as well as how many people received assistance and how much assistance recipients got. I'm not sure what the basis was for state marketplaces for the ACA but the history of involving states seems to make everything worse. Adding an intermediary allows programs to be scuttled and money diverted (if not outright stolen) by other programs and participants. As an example, Texas refused free money from the Federal government for Medicaid expansion, amounting to $5-6 billion per year [2]. [1]: https://www.cbpp.org/research/income-security/lessons-from-tanf-block-granting-a-safety-net-program-has-significantly https://www.cbpp.org/research/income-security/lessons-from-t... [2]: https://www.statesman.com/story/news/politics/politifact/2022/01/09/texas-turned-down-100-billion-when-decided-not-expand-medicaid/8858664002/ https://www.statesman.com/story/news/politics/politifact/202...
  • ThunderSizzle 3y ago
    To be fair, there is no such thing as "free money". Every "free" dollar the feds give out is that much more inflation and devaluation of the dollar, and it's been skyrocketing every since the Feds started giving out this type of free money to the states. I doubt Texas refused on this principal, but states viewing Federal money as free is irksome. It's not free. It's a hidden tax on both your current citizens in terms of devaluation of their savings, and future citizens to pay off the debt the Feds are creating with this "free" money. Talking about inefficiency - it'd probably be significantly more efficient to stop requiring this money to funnel through DC. But it's more about power than efficiency.
    • ceejayoz 3y ago
      The sick people don't go away if you don't fund Medicaid. (Well, some do, but not the cheap way.)
      • albert180 3y ago
• beanjuiceII 3y ago
  how does one person shut down a govt?
  • Tostino 3y ago
    By having a brittle system held up by "norms" that were simply ignored.
  • Rebelgecko 3y ago
    The US government has an annual budget. Normally before a new year starts, there needs to be a new budget. The House of Representatives nominally has the full responsibility of creating the budget, but it's also subject to approval by the senate and president. IIRC, in 2013 Republicans had control of the house and didn't pass a new annual budget. In the last few weeks of the year they did pass a continuing resolution saying something along the lines of "continue the government funding for 2 months at last year's levels until we pass a more complete new budget, and also repeal the Affordable Care Act". The Senate voted in favor of most of the continuing resolution but not the ACA repeal, which caused deadlock when the HoR and Senate couldn't reconcile the 2 versions of the bill that passed.
• paulusthe 3y ago
  The state-run exchanges solution was itself a compromise for Republicans and on the fence Democrats, particularly Arlen Specter, who feared a federal healthcare system would inevitably lead towards universal healthcare. They received their compromise, then refused to implement the exchanges in the hopes that the law would die. It didn't, and they're still mad about it.
  • soderfoo 3y ago
    Also, the public option was scuttled due to Senator Joe Lieberman, presumably due to his close ties to the insurance industry.
    • lozenge 3y ago
      As I understand it it's common for one Dem senator to "take the PR hit" when there are actually multiple members who would not want a bill to pass. A bit of kayfabe.
• HealthcareGov23 3y ago
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• listenallyall 3y ago
  > That government shutdown in 2013 was instigated entirely by one U.S. Senator, Ted Cruz, expressly for the purpose of sabotaging ACA You say it like it's a bad thing. ACA is horrible -- extremely expensive, few options, huge deductibles, virtually zero transparency, "keep your doctor" turned out not to be true in many cases. I'm no Ted Cruz fan, but I wish more people had stood up and admitted this thing was a total piece of shit and tried to prevent it from passing.