Monday, April 09, 2018

The Smartest Boys In The Room

Too much of the conversation about Obamacare gets stuck in the great battle of '09, the public option vs. the not public option. For a variety of reasons the public option could've and likely would've solved many of the problems with Obamacare (mostly meaning the exchanges, all the regulatory stuff about insurance generally was mostly good), but the problems of Obamacare weren't simply "private insurance and our health care system generally sucks." Obamacare was badly designed in a lot of other ways, some of which probably could have been fixed without pissing off Joe Lieberman, and some of which were a demonstration that the smart guys who designed the thing weren't nearly as smart as they thought they were. They fucked up.

When ObamaCare was being designed and negotiated, many liberals confidently predicted it would make large changes to the basic structure of the American insurance system. Everywhere would have a robust private insurance marketplace that would provide insurance that was just about as good as anything else you could get. That accomplished, perhaps even employers might start pushing their employees onto the exchanges, and we could finally start demolishing the incredibly dumb and inefficient employer-provided insurance system. Though there are some requirements for larger employers to provide insurance in the law, the Congressional Budget Office still predicted a moderate decline in the fraction of Americans getting coverage through their employer.

That hasn't happened at all. The employer market has declined slightly, but only following the pre-ObamaCare trend. Meanwhile, the exchanges have mostly settled down into a weird, funhouse-mirror simulation of Medicaid disguised as a private market — useful almost entirely for lower-income people who are eligible for subsidies. As Vanderbilt health policy professor John Graves told Vox's Dylan Scott, "the marketplaces are really functioning more broadly in their role as an extension of the public safety net than in their role as a competitive market."

It wasn't simply an ideological debate or even a debate over what could get Joe Lieberman's votes. It was also a debate between technocrats, but the ones on the inside declared (as always happens) that they were the Very Serious People, the wise wonks with a monopoly on mad technocratic skillz, and that their critics were just unrealistic children looking for unicorns.

As with many things, admitting fault isn't just about self-flagellation, it's necessary for moving forward. Obamacare "fixes" - if ever they are possible to pass - will likely compound the problems unless the architects acknowledge its flaws or they are replaced.