Saturday, December 03, 2016

The Dirty Truth About Obamacare

Obamacare is so messy and troubled, even President Obama doesn't like Obamacare. He can't admit it publicly, of course, but I'm sure it's the case. And if the man isn't proud of his signature achievement, that pretty much means he must be the worst president ever...right?

Nope. The unpleasant but inescapable fact is, politics is the art of the possible[6]. The Obama administration decided that tinkering around the edges was the most that could be accomplished. No single-payer, certainly no National Health Service[1][2]. Tinkering around the edges inherently involves what we computer nerds might call "a pile of hacks". It's a miracle it works at all, and it's certainly not pretty, and it is very fragile. That's Obamacare.

We can quibble in hindsight. On the left, many wished for something grander. On the right, many wished for nothing--though they won't admit that now. Because here is the real dirty truth. The American healthcare "system" is hardly a system. It is a Frankenstein monster that was started by accident[3], and continued to grow first because nobody recognized the danger, and then because nobody had the courage to do something. You can't find an economist or public health expert, and hardly a hospital administrator or physician, who has much good to say about it. The system is shot through with flaws, perverse incentives, inefficiencies, false premises and conflicts of interest.

It has been this way my entire adult life (I was born in 1965), and then some. And all that time, a succession of administrations, some Democratic and some Republican, came and went without trying too hard to fix it. On the Democratic side, there were sporadic efforts. The shining exception would be Medicare. It has imperfections[4], but all-in-all, it's a pretty coherent, cost-efficient system that provides effective coverage and care. And of course the Clinton administration tried something grander, but we all know how that turned out.

Mostly, the Republicans did nothing[5]. Other than periodically resorting to the empirically false defense of claiming "America has the best healthcare in the world, [thus it must be worth the cost]". So Obamacare is terribly imperfect, but it is a SOMETHING that is better than the longstanding alternative of NOTHING.

Politics is the art of the possible. A pile of hacks. That's all Obamacare is. At least in Round 1. Because here is the other thing. Incrementalism is like compound interest or regular exercise. Its effects are imperceptible from day-to-day, but over time, it can be transformational.

Thus, I also believe that Obama, thoughtful political scientist and patient human that he is, hoped the initial Affordable Care Act was the start of something bigger. A mere opening move, a means to break the logjam of do-nothing inertia. A program that could be iteratively improved, or perhaps even completely replaced with something much more ambitious. Unfortunately, in calculating the worst case, Obama underestimated the intransigence and tribalism of the contemporary Republican Party Party of Donald Trump.

So unimproved Obamacare is all we get. Not so much, but definitely better than nothing. (To those who couldn't afford health insurance but now can, probably much, much better than nothing.)

While Obama undoubtedly recognizes, and surely deplores grieves, the imperfections of Obamacare, he can rightly take pride in it. And much more pride in the political leadership he provided in enacting it. Obama did what he could to push the the nation forward, and his reward was to incur the wrath of the Party of Donald Trump, and bitter disappointment from the left. As a passionate centrist, and an empiricist, I love Barak Obama more than any president or politician I can think of. I will miss him very much.


NOTES
[1] Single-payer is not synonymous with "socialized medicine". It does not require that the government run the whole system--employer of all healthcare providers and provider of all hospitals and other facilities.

[2] Also, contrary to popular hearsay belief in the U.S., the NHS doesn't actually suck, at all.

[3] Ironically, the seeds were sown largely by misguided government tinkering (WWII wage and price controls) and tax policy (exempting employer-paid premiums from income tax).

[4] Those imperfections are mostly related to under-"reimbursement"--not paying enough for procedures. That is an effect of the coherent sub-system of Medicare trying to exist within the larger Frankenstein system. 

[5] The odd exception of George W. Bush passing Medicare Part D--prescription drug coverage. Making the most functional part of the monster much better, but doing nothing to improve the rest of the system. The political calculus probably being that this would be a very good way to court elderly votes, and since it didn't mess with the overall system, it wouldn't inflame entrenched ideologies and interests.

[6] Clear corollary: any politician who promises "no compromise" should immediately be rejected as a cynical liar, or hopelessly naive.

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