Problems With ObamaCare After One Year, According To Megan McCardle

See ObamaCare, One Year In. Excerpts:

"3. The budgeting problems are even worse than I thought I argued at the time that the spending cuts were not sustainably structured, but I didn't predict just how difficult they would prove to sustain. Already, Congress is resorting to ever-more-desperate health care budget gimmicks, like dipping into the health insurance subsidies in future years in order to pay for higher Medicare physician reimbursements. A month or so after it passed, a healthcare reporter of my acquaintance said that he thought that Congress had pretty much used up every conceivable pay-for in order to pass PPACA, and history is so far proving him right: having exhausted their pay-fors, they've now started cannibalizing ObamaCare itself. And it's three years to go before we actually set the Rube Goldberg machine into motion.

4. Unintended consequences have started kicking in As the Official Blog Spouse points out, the administration is granting waivers to virtually anyone who asks, presumably because they think that absent the waivers, people would be losing their insurance. And not without good reason--thanks to the rules making it illegal to exclude children with pre-existing conditions, insurers have now stopped selling child-only policies in 34 states. Both the government of Massachusetts and the administration are eagerly exploring the option of simply commanding insurance companies to sell policies at the price they would like to pay, a tactic that doesn't really have a great track record in modern industrial economies.

5. It turns out maybe it's not so obvious that it's constitutional At the time of passages, court challenges were dismissed by the bill's supporters as a bunch of fringe quackery--no thinking person could imagine that the Supreme Court could find PPACA unconstitutional. Now it's not so far-fetched--not the most likely outcome, but a distinct possibility. And because no one thought it was possible, the act is not well structured to survive a court challenge. Not only is it missing a severability clause, but the administration's insistence that the mandate wasn't a tax has basically robbed them of a backup strategy--if the court rules that they don't have the authority to do this under the Commerce clause, there doesn't seem to be much hope they can work it in under the taxing power instead.

I wanted to include the upside surprises, but I honestly couldn't think of any. Suspecting I was biased, I looked to Kathleen Sebelius's recent testimony, which doesn't really offer much in the way of serendipitous success--the things that Democrats say are going okay aren't surprises, and also in many cases, according to the Washington Post, aren't true.

Of course, I imagine that at this point supporters are saying that the best is yet to come--that ObamaCare just hasn't really gotten going yet. Perhaps so! But this is the one year report card, and the first-year grades are pretty underwhelming."