Personal Health  
comments_image Comments

Could Obamacare Have Been Better?

Even with the Affordable Care Act, about half of America's uninsured will not be helped, and many people with employer-provided insurance will face rising premiums.

Photo Credit: Rodrick Beiler


I've taken a fair amount of heat for a post that I wrote two weeks ago in this space titled "Obama's Gift to the Republicans."

The gift is, of course, the Affordable Care Act. I wrote that it was botched not only in execution but in conception, as well as in the failure of White House leadership to pay close attention to the details long before went live more than three years after the law was signed.

The liberal critics have made four basic points against my argument, and a nice summary is contained in a piece posted Friday on the New Republic site co-authored by my old friend Henry Aaron of the Brookings Institution and Harold Pollack of The University of Chicago. (Their piece is titled, "Now's Not the Time for Liberals to Say 'I Told You So' About Obama.")

Point one is that that universal single-payer health insurance, the efficient alternative, was never in the cards legislatively. Point two is that if Obamacare is complicated, it's because the health system is complicated. The third point is that the Affordable Care Act, whatever its blemishes, is actually helping a lot of people.

The final point is that the news is getting better -- the government is slowly getting the bugs out of the software, and in state-run exchanges such as those of California and Kentucky, large numbers of people are actually enrolling. Paul Krugman, in recent columns, makes many of the same arguments. A further tacit argument is that with Republicans gleefully hoping to destroy the program, the president, and the Democrats, this is no time for liberals to pile on.

Let's take these one at a time.

Could we have done better? If not Medicare-for-All in a single stroke, maybe incremental progress towards single payer?

Readers may recall something called the Public Option. The idea, brainchild of Yale political scientist Jacob Hacker, was to create an option for people under age 65 to buy into Medicare. Since Medicare is so much more efficient than private insurance, over time the Medicare option (later re-branded the Public Option) would gradually drive out private insurance.

A broad coalition of progressive groups backing Obama's reform (Health Care for America Now, or HCAN) insisted that the Public Option be part of the legislation and part of the deal. But when Obama decided to strike his own deal with the insurers and the drug companies instead, he threw the HCAN coalition under the bus. HCAN, though undercut, gamely continued to push for the legislation. (Why does that saga have such a familiar ring? But I digress.)

The idea of a public mandate for people to buy private insurance, with a government subsidy for the poor and near-poor, was a conservative idea first pushed by the Heritage Foundation and first implemented by Republican governor Mitt Romney of Massachusetts. Federal alternatives, which would have moved us towards genuine universal and public health insurance, included:

  • The Public Option
  • Extending Medicare to young adults and children
  • Allowing people over 55 to buy into Medicare
  • Expanding Medicaid (this, in limited form, became part of the ACA)

With the exception of the last item, which the Supreme Court has made voluntary to the states, President Obama did not use his bully pulpit to exercise presidential leadership on behalf of more public alternatives. So the contention that Medicare for All, done incrementally, was never a legislative possibility, is just conjecture. We don't know because for the most part Obama didn't try. (He did half-heartedly raise the Medicare buy-in at 55, but didn't really push for it.)