Could Obamacare Have Been Better?

Personal Health

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.)

We do know, in response to point two, that the ACA makes a dizzying complex system that much more complex. And far from gradually displacing the inefficient central role of private insurance companies, the ACA reinforces that role.

As for points three and four, it's true that the ACA will help a lot of people and that the cursed website is slowly becoming operational. People with pre-existing conditions, people under 26, people who lose health insurance when they change or lose jobs, will all be helped. Small business will eventually be helped, too.

But about half of America's uninsured will not be helped, and a lot of people who have employer-provided insurance will find their premiums rising. (The Wall Street Journal recently reported that because the mandate will cause more employees to sign up for company-provided insurance that they previously declined, employer costs will rise and businesses are planning to pass these higher costs along to all employees through higher premium-shares, deductibles and co-pays. Obama and Democrats are likely to get the blame.

So even if Obamacare does help a lot of people, my question was and is: at what political cost and at what long-term cost to effective social insurance? Both the conception and the roll out of The Affordable Care Act will set back the effort of liberal Democrats to persuade regular people that government can be a force for the broad public good (Social Security has no such problems). The ACA is the social-policy equivalent of the Pentagon's apocryphal $800 hammer. Even with a great deal of catch-up and good luck, it will take a miracle for Obamacare not to be a net loser for Democrats in the 2014 mid-term elections.

I don't buy the argument that liberal commentators like me have some kind of obligation to stand by their president when he messes up. As the terrific reporting of the New York Times has demonstrated, the failure to get the website up and running was substantially preventable and politically inept if not inexcusable.

Nor do I accept the charge of piling on, or reveling in the role of I-told-you-so.

Despite the debacle, I am with my friend Hank Aaron in hoping that they fix this mess, the sooner and more effectively the better -- because the failure of the ACA taints reformers who are more resolute in their progressivism than the Rube Goldberg imitation of liberal government that bears our president's name.

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