Mickey Kaus points out some of the issues in the PPACA that are becoming apparent as the program actually gets off the ground:
We know what happens when people who claim subsidies on the Obamacare exchanges underestimate their income–the IRS will grab the unwarranted part of the subsidy back at tax time. And we know what happens if they overestimate their income–they’ll be refunded the subsidy to which their lower income entitled them.
But the poorest Americans don’t qualify for subsidies on the exchanges. If they make less than the poverty line –about $20,000 for a family of three–they’re steered to Medicaid. (In states with expanded programs, they’re apparently sent to Medicaid if they make less than 138% of poverty, according to the Kaiser subsidy calculator). So what if someone is near the income boundary between the two programs–and what if this person overestimates their income, and thinks they qualify for a subsidized policy on the exchange–but it turns out they didn’t make what they thought they’d make. Maybe they didn’t get some work they usually got in the past, or their wages got cut, or they got laid off. According to the income they actually earned, they should have been sent to Medicaid. They didn’t just get too much or too little subsidy. They used the wrong program.
And then there are the impossibility for many people of knowing what their income will actually be, the incentives for cheating, and so on. I don’t think it’s just a case of the problems that occur when any major program is rolled out. I think it’s a problem of when a program is prepared in haste and implemented by people who aren’t particularly detail-oriented, don’t really know very much about the healthcare system as it exists in practice, and are predisposed to make terribly bad decisions based on a flawed notion of human nature. Not to mention that they might be motivated to make their decisions based on the politics of the situation rather than its pragmatics.
All of this points to the preferability of doing something like the PPACA on a state-by-state basis so that at the very least the problems that inevitably emerge won’t be happening everywhere at once and the damage can be controlled. There are, after all, real people with real problems and real lives that are at stake.