The big kludge
The good news about HealthCare.gov, the portal to Obamacareís health exchange, is that the administration is no longer minimizing its problems. Thatís the first step toward fixing the mess ó and it will get fixed, although itís anyoneís guess whether the new promise of a smoothly functioning system by the end of November will be met. We know, after all, that Obamacare is workable, since many states that chose to run their own exchanges are doing quite well.
But while we wait for the geeks to do their stuff, letís ask a related question: Why did this thing have to be so complicated in the first place?
Itís true that the Affordable Care Act isnít as complex as opponents make it out to be. Basically, it requires that insurance companies offer the same policies to everyone; it requires that each individual then buy one of these policies (the individual mandate); and it offers subsidies, depending on income, to keep insurance affordable.
Still, thereís a lot for people to go through. Not only do they have to choose insurers and plans, they have to submit a lot of personal information so the government can determine the size of their subsidies. And the software has to integrate all this information, getting it to all the relevant parties ó which isnít happening yet on the federal site.
Imagine, now, a much simpler system, in which the government just pays your major medical expenses. In this hypothetical system you wouldnít have to shop for insurance, nor would you have to provide lots of personal details. The government would be your insurer, and youíd be covered automatically by virtue of being an American.
Of course, we donít have to imagine such a system, because it already exists. Itís called Medicare, it covers all Americans 65 and older, and itís enormously popular. So why didnít we just extend that system to cover everyone?
The proximate answer was politics: Medicare for all just wasnít going to happen, given both the power of the insurance industry and the reluctance of workers who have good insurance through their employers to trade that insurance for something new. Given these political realities, the Affordable Care Act was probably all we could get ó and make no mistake, it will vastly improve the lives of tens of millions of Americans.
Still, the fact remains that Obamacare is an immense kludge ó a clumsy, ugly structure that more or less deals with a problem, but in an inefficient way.
The thing is, such better-than-nothing-but-pretty-bad solutions have become the norm in American governance. As Steven Teles of Johns Hopkins University put it in a recent essay, weíve become a ďkludgeocracy.Ē And the main reason that is happening, Iíd argue, is ideology.
To see what I mean, look at the constant demands that we make Medicare ó which needs to work harder on cost control, but does a better job even on that front than private insurers ó both more complicated and worse. There are demands for means-testing, which would involve collecting all the personal information Obamacare needs but Medicare doesnít. There is pressure to raise the Medicare age, forcing 65- and 66-year-old Americans to deal with private insurers instead.
And Republicans still dream of dismantling Medicare as we know it, instead giving seniors vouchers to buy private insurance. In effect, although they never say this, they want to convert Medicare into Obamacare.
Why would we want to do any of these things? You might say, to reduce the burden on taxpayers ó but Medicare is cheaper than private insurance, so anything taxpayers might gain by hacking away at the program would be more than lost in higher premiums. And itís not even clear that government spending would fall: the Congressional Budget Office recently concluded that raising the Medicare age would produce almost no federal savings.
No, the assault on Medicare is really about an ideology that is fundamentally hostile to the notion of the government helping people, and tries to make whatever help is given as limited and indirect as possible, restricting its scope and running it through private corporations. And this ideology, at a fundamental level ó more fundamental, even, than vested interests ó is why Obamacare ended up being a big kludge.
In saying this I donít mean to excuse the officials and contractors who made such a mess of health reformís first month. Nor, on the other side, am I suggesting that health reform should have waited until the political system was ready for single-payer. For now, the priority is to get this kludge working, and once thatís done, America will become a better place.
In the longer run, however, we have to tackle that ideology. A society committed to the notion that government is always bad will have bad government. And it doesnít have to be that way.
Paul Krugman is a columnist for The New York Times.