The Survival of Obamacare: What is Government Good For?

Yes, I’m still celebrating the collapse of the bill that was supposed to put an end to Obamacare.[1]

I’m celebrating because the proposed repeal-and-replace law would have taken health care coverage away from 24 million people while delivering big tax breaks to those who need them least.  And remember Kathy, who has COPD and can’t afford oxygen?  With Obamacare intact for now, states can still expand Medicaid to help folks like Kathy, and in Maine we will have a chance to do so by referendum if our Governor blocks expansion again.

So I’m rejoicing that disaster has been averted, but I’m pondering why on earth such a proposal ever got off the ground.  Why did it appeal to so many people that it became a popular campaign promise – a terribly destructive promise, but one on which the President and Congress seemed ready to deliver, until their coalition for demolition fell apart.  Why was that promise, inexplicably made, abandoned so soon?

Obamacare is a creative, middle-ground health care solution, based on a bipartisan plan that worked in one state that tried something similar.  It’s also a complex law fraught with imperfections due to the circumstances of its creation.  With that history, it’s not a surprise that folks who saw their rising health plan costs swallowing their household budgets, or who tangled with one of the new law’s glitches, believed repeal advocates who told them that things would be better without it.

The repeal argument rested on the conservative idea that reducing the size and power of government is the key to solving our social problems.  I imagine that many to whom “repeal Obamacare” sounded good weren’t much interested in that idea.  They were looking for whatever change it might take to end the gnawing insecurity of a fragmented and increasingly unaffordable health care system.  They were frustrated and afraid of getting sick and having no help, or breaking their budgets to keep their insurance.  Maybe “repeal” sounded like a decisive way to banish the fear and frustration.

On March 13, the nonpartisan analysts at the Congressional Budget Office reported on the impact of the proposed replacement, predicting the loss of health care for 24 million people and noting especially severe impacts on the elderly.  The CBO analysis revealed that in the case of Obamacare, shrinking the program wouldn’t help – it would make matters much, much worse for many.

While Obama was President, Republicans could express emotional solidarity with those frustrated by unaffordable health care by voting for repeal, counting on the President to veto the measure.  They could rely on the myth of small government, knowing that it would not be tested.

Now, with full control of the federal government and President Trump ready to sign the bill, some Republicans saw that scaling back or repealing Obamacare would hurt more people than it would help; it would fail to fix what’s broken.  That truth, at least partly understood by the odd coalition of pragmatists and ideologues who thwarted the American Health Care Act, stopped “repeal and replace” in its tracks.

The small-government myth at the heart of the repeal movement rests on the notions that (1) government is inherently inept and (2) self-interested individuals can solve large-scale social challenges through the magic of a free market.

But government isn’t inherently inept.  Like any other large-scale human endeavor, it can be clumsy sometimes, and really big undertakings, like reforming health care, require tinkering and interactive adjustment to reach their goals.  That clumsiness looks and feels worse when, as was the case with Obamacare from the beginning, one party in the government makes a sustained effort to thwart the project at every turn.

There are, of course, things that government can best leave to unfettered markets, like ensuring fair prices and good supplies of vegetables or shoelaces.  The trouble is that health care isn’t like shoelaces or broccoli.  It’s more complex, and our needs for it vary vastly from person to person and year to year.

Without a society-wide system for providing health care, all but a few who are especially wealthy are one unexpected illness away from financial ruin. We need a means of ensuring that the vast array of expertise and equipment that can serve to improve our lives and our capacities for work and play when we get sick are available to each of us when needed.  This is what industrialized countries with sophisticated health care systems do.  We are the wealthiest and most powerful of those countries, and we can do it too.

Now that Obamacare’s opponents have tried driving backwards and found that it was too risky, can we move ahead, with the ACA as our starting point?  It’s what we’ve got, and we can make it better and more sustainable.  We can

  • focus on how to fix the system, not on who wins a political game by pinning unsolved problems on someone else;
  • find ways to control costs system-wide, even if effective cost saving measures offend powerful interests;
  • extend, not shrink the subsidies for private insurance;
  • cover all low-income people under Medicaid, up to whatever level makes sense to be sure private insurance is viable and affordable for those who use it;
  • correct the glitches that leave people out and the ones that make health plans for others needlessly expensive.

In short, instead of pretending that shrinking government is always the answer, we can be pragmatic and creative, using the powerful tools of government when they are best suited to acting together to solve big problems.

This lesson applies beyond health care.  There are many endeavors in modern life that can’t be successfully handled through the self-interested actions of individuals in a free market.  In fact, free markets themselves require government action to work properly – over a century ago, the United States had to enact tough criminal penalties against anti-competitive behavior to ensure that large companies would compete instead of getting together to raise prices.

A strong government, accountable to the electorate, is often essential to serve community goals, so that the interests of private concentrations of money and power do not overshadow the public good. The question is when and how to fashion government programs that serve our common interests efficiently and well, and when to leave private actors to function without such programs.

These choices can’t be made by shrinking government to the point where people are left without essentials such as health care; they must be made by paying constant attention to the efficiency and accountability of government, while acting with a well-founded confidence that human beings, working together, can use the tools of government to protect and advance the freedom, safety, and prosperity of the whole community.

[1] I’m grateful to Mitchell Stein for his rapid yet lucid and thorough response to the events of March 23 and 24. His commentary, and the many links he included, furnished much food for thought.

Charlie Dingman

About Charlie Dingman

Charlie Dingman likes to write and talk about politics, economics, and law. Through this blog, he hopes to share with you some of his thoughts about those subjects, and how they connect to our daily joys and struggles, and to the highest values of humanity.