When talking about issues with the Affordable Care Act it’s important to remember its problems fall into three basic categories: Implementation, Design, and Foundational.

Most of the currently focus has been on implementation problems. Agencies not doing the job they were supposed to do. These include a broken website or not getting information to the insurers. These are serious short-term issues caused by incompetence but they are fixable. They can be fixed, with time, if the administration hires the right people.

Design problems are caused by basically sound concepts being structured in stupid ways. There is nothing inherently problematic with the idea of requiring companies to provide insurance or giving individuals subsidies. The problem is how these provision were written in the ACA. By creating an exchange subsidies cliff or a poorly designed free rider provision the law created design problems which could have been avoided. Congress needs to slightly amend these provisions to fix them, but that appears very unlikely in the near term. Design problems stop the law from working as it was conceived.

Foundational problems are more meta. They are issues with even the basic concepts behind the law. The whole idea that regular people easily going to make the right decision when faces when incredibly complex insurance choices is fundamentally unsound. Even if the laws’ individual provisions were designed better these issues would remain. These problems can only be fixed with broad reforms.

The implementations problems should be short-term and are getting fixed. Once they are fixed the focus will turn to the design and foundational issues. Unlike the implementation problems, these could take years if not decades to correct.

Photo by felishumanus, used under Creative Commons license