Blame Obama for Obamacare's issues. Don't blame "government health insurance."

October 25, 2013

It's true: the rollout of the Obamacare federal exchange has been a mess. And while the problems began with technical issues, they're threatening to become a whole lot more.

This week's Capitol Hill circus was all about who's to blame. Is it the feds' fault or the contractors'? To those of us who, whatever our political sympathies, don't have an immediate dog in the blame game, the answer seems obvious: regardless of where the specific problems originated, it was the Obama administration's job to get this thing done. And the administration failed.

So it's not much of a rhetorical leap to go from "the exchanges are a mess" to "the federal government is bad at things" (also here, lots of other places). But this obscures more than it reveals, because the things that make Obamacare such a heavy technical lift are the same things that make it very much not a government takeover of health insurance. Mike Konzcal explains this as the difference between neoliberal social insurance (means tested, market based, a lot of state discretion, with a premium on choice and competition) and traditionally liberal social insurance (universal, public, federally run, with a premium on outcomes). Obamacare in general—and the exchanges in particular—are largely the former. This, not general government incompetence, is what makes them so complicated.

An actual government takeover of health insurance was, of course, politically impossible. But it would have been a hell of a lot easier to implement. So please, blame Obama and Sebelius and the Centers for Medicare and Medicaid Services for dropping the ball on implementation. But don't blame the very notion of a public role in health coverage for the problems of a law that goes way, way out of its way to limit this public role.

As is often the case, Ross Douthat offers a smart and sober right-of-center take: a failure of the exchanges would probably lead eventually to more socialized health insurance, not less, because Medicaid would expand as planned, and new energy would emerge around lowering the age for Medicare eligibility. (Unlike the Obamacare exchanges, these are actual government-run health-insurance programs.) Douthat goes on to spell out the policy debate over whether this would be a good thing:

[Liberals might legimitately say,] just look at the difference between what Medicaid spends and what our private insurers pay out. There’s no comparison: If you want people to spend less on health care, socialized medicine rather than catastrophic coverage is obviously the way to go.

And this is where we start to really get down to ideological bedrock, because conservatives and libertarians (and a few liberals) then look at the European/Canadian model and say, Surely there’s a better way than that. Yes, we concede, the strictly socialized systems do seem to save money relative to our mixed, kludge-y, public-private mess. But we also think that Americans really do get something for all the extra money that we spend: Specifically, a system that appears to drive a leonine share of global health care innovation.

Douthat ultimately prioritizes this bottom-up, market-based innovation; I'd rather see more people gain access to routine care that already exists. That's a real debate, and an important one. Which is more than you can say for the idea that the Obamacare exchanges' problems prove that the government can't do anything right.