Obamacare may or may not survive its inauspicious beginnings. It has become dangerously unpopular and accident-prone and faces a minefield of difficulties. Still, the Obama administration has a plausible strategy: to titrate the program’s numerous taxes, subsidies, mandates, and restrictions so as to forestall immediate legislative or electoral reversal, thereby entrenching its basic structure for tightening as future circumstances permit.
But the drama has made one thing clear: Obamacare will never achieve its promise of affordable health care for all paid for with improved efficiencies in health insurance and medical care. The initial troubles and compromises have revealed that the program improves “access” mainly by herding millions of people and firms into insurance they do not want or need. A great many will simply refuse, having little to fear for the time being, with the result that government expenditures will be far higher than projected. It is equally clear that the variety and quality of medical care will be seriously restricted for all concerned.
Collaterally, Obamacare is introducing a new form of government—improvisational government, characterized by continuous ad hoc revisions of statutory law by executive decree. This is a reversion to a primitive form that long antedates our Constitution and rule-of-law traditions. Transported to the modern world, it leaves the private sector in a state of constant uncertainty and subjection.
These developments have produced a strong partisan reaction. Republicans are commiserating with individuals who have lost their health insurance or seen their rates increase, and are introducing tactical bills to stay unpopular program elements. Obamacare was a partisan enactment and was designed, clumsily, in such a way as to generate identifiable victims—so the partisan response was inevitable and is, up to a point, serving a worthy function of public education.
Two further responses are deeper and more arresting. First, many prominent Republicans and conservatives—lawmakers (Paul Ryan), academics and think tankers (John Cochrane, Thomas Miller), and intellectuals and journalists (Yuval Levin, Ramesh Ponnuru, Holman Jenkins)—have come forward with specific proposals for expanding affordable health care more than Obamacare does, while eliminating its many harmful and unworkable features. Tax and regulatory reforms, and targeted public subsidies, would provide portable and renewable insurance, including for those who have developed costly health conditions; would legalize (rather than banish) low-cost insurance for essential medical services by replacing special-interest coverage mandates with sensible minimum standards; and would encourage direct purchase of routine medical goods and services where insurance has nothing to offer but paperwork. Conservative reformers would also put Medicare and Medicaid on a budget—something all knowledgeable observers know to be imperative to sustaining the programs and bringing government deficits down to manageable levels. At the same time, the programs would be converted from monopoly to competitive supply through vouchers, “premium support,” and greater variety in addressing the special needs of the very poor.
There are important differences among these proposals, and much room for debate. But they have one thing in common that is highly admirable, whatever one thinks of their merits: They transcend, in fact defy, the opportunities of the moment to score partisan political points. To be sure, they would dispense with many unpopular Obamacare provisions; but they go further and aim higher—to correct the harmful preexisting conditions in American health care that Obamacare promised to correct but is making worse. And that is a risky proposition when the public is angry and suspicious over government meddling with health care. Are Americans prepared to part with the illusion that everything related to “health” should be available free or far below cost, and that this can be done without degrading medical practice and risking eventual bankruptcy? Will they distinguish between higher-priced insurance for medical services they don’t need and insurance that leaves them to pay directly for services they do need but are quotidian and noncontingent? Do they understand that competition and innovation are as valuable in health care as in smartphones and coffee shops? Will they recognize that further expanding Medicare and Medicaid, when that is offered as the cure for Obamacare’s failures, is a quack remedy? The conservative reformers are betting that the public, now that it is paying attention, will answer in the affirmative. They may be right, but they need help.