Robert Samuelson November 12, 2013

For President Obama, the one “must read” from the latest Sundaypapers is an essay in The Post by Jon Kingsdale, who ran the healthexchange for the Massachusetts program of mandatory insurance from 2006until 2010. Kingsdale — a backer of the Affordable Care Act, or“Obamacare” — thinks the administration faces lots more problems, evenif the HealthCare.gov Web site eventually gets up and running.

Kingsdale says that in Massachusetts, a reliable Web site was only a modest worry. (Disclosure: Kingsdale and I once worked for the sameemployer and knew each other. But we haven’t spoken for many years.)Much harder was getting “enrollment, billing and premium collectionsworking smoothly.” Here’s why:

“Enrollees are not covered untiltheir first month’s premium is received. In the individual insurancemarket, premium billing and collection [are] difficult to track. Folksfrequently pay late or in weekly installments, or send too little oreven too much. And when they stop paying, they often do not notify theinsurer; the company must determine whether it is an intentionaltermination, an oversight, or a lost or late payment. . . . If insurers cannot track and collect premium dollars each month, theextra work of doubling back with customers and insurers will frustrateconsumers and delay coverage. And a mounting backlog could eventuallycompromise the fiscal integrity of the exchange.”

Translation:Assuming the Web site is completely fixed, Obamacare’s woes could stillslow its introduction or, at worst, result in its collapse.

Onedanger for the administration, Kingsdale says, is much higher premiums.If people are frustrated in signing up or staying signed up — especially among so-called “young invincibles” whose premiums are supposed tosubsidize older, sicker people — then insurance companies will raisepremiums to cover costlier enrollees. Higher premiums for 2015 (mostrates are set for 2014) will become public next fall, just weeks beforecongressional elections, Kingsdale notes. Obama’s greatest legislativetriumph could backfire big time.

Without intending it, Kingsdalehas, I think, identified a central source of Obamacare’s problems: Thepeople who created the program had no idea how it would be put intoeffect. They just took it for granted that the law would be implementedand perform, more or less, as intended. This attitude blendedcarelessness, ignorance and arrogance, reflecting a broader problem inbusiness and government.

There’s a class structure to huge publicand private organizations. One class — usually the leaders ofenterprises or departments — might be called the Pontificators. Theyenunciate broad, often-worthy goals and values. President Obama (indeed, almost any president) ranks as the Pontificator in Chief. In politics,elected officials and pundits (people like me) are lower down on thePontificator scale. In business, these people cluster in the executivesuites.

But most workers belong to the Plumber class. They’re thefix-it folks. They’re supposed to put the Pontificators’ pronouncementsand commands into effect. Never mind that these demands are oftenimpractical, inconsistent or uninformed because the Pontificators haveonly a sketchy notion of what the Plumbers do or what the real worldrequires.

Writes Kingsdale of Obamacare:

“A healthinsurance exchange is more than a Web site. It is an insurance store,and to manage it well requires insurance experience, technical know-how, and savvy marketing and sales tactics.”

Precisely. Whether the administration recognizes this and still has the time to act on it are crucial and open questions.