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posted: 10/6/2013 5:00 AM

Reforming Obamacare

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After much struggle and internal strife, Republicans seeking to block Obamacare have arrived at this achievement: Much of the government is closed -- except for Obamacare. The national parks are deserted but the health exchanges sputter and wheeze to life.

For the most vigorous critics of President Obama's health reform, this failure is a point of ideological no return. "The administration's plan," says Sen. Ted Cruz, R-Texas, "is to get as many Americans as possible addicted to the sugar, addicted to the subsidies. And in modern history, there has never been a major entitlement that has been implemented that has ever been unwound. ... If we don't defund it now, how do we ever successfully get rid of this train wreck of a law?"

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Cruz goes on to argue that the administration's decision to delay the employer mandate is instructive. "If Obamacare were going well, if it were working, he would want it to kick in before the election. The fact that he and Democrats are very, very concerned about being held accountable at the polls for the train wreck that is Obamacare is very revealing." There are two very different arguments being made here, leading to a clash of metaphors. Americans, apparently, are on the verge of being addicted to a train wreck. Voters are about to become hooked on a political disaster that Democrats wish to delay.

Tea Party conservatives have not only embarked on a legislative confrontation without an endgame, they have made a hash of their Obamacare critique. Both their apocalyptic urgency before implementation and their fatalism after it are rooted in a misunderstanding of the law itself.

Obamacare is not primarily an entitlement program. The entitlement component -- the exchange subsidies -- will involve about 2 percent of Americans during the first year. (Others will be added to Medicaid, which has been around since 1965.) About 20 million Americans will eventually get subsidized insurance -- a check that goes not to the individual but to insurance companies. The remaining 170 million Americans will not experience Obamacare as a sugary treat but as a series of complex regulatory changes that may make their existing insurance more costly, less generous and less secure.

The main problem with Obamacare is not its addictive generosity; it is its poor, unsustainable design. Its finances depend on forcing large numbers of young and healthy people to buy insurance -- yet it makes their insurance more costly and securing coverage less urgent. (Because you can get coverage during each year's enrollment period at the same price whether you're healthy or sick, the incentive to buy coverage when healthy is much diminished.)

Heavy insurance regulations will lead some employers to restructure their plans, dump employees into the public exchanges or make greater use of part-time workers. In order to meet a few worthy goals -- helping the poor buy insurance and covering pre-existing conditions -- Obamacare seems destined to destabilize much of our current health system.

As a political matter, Obamacare will not keep many of its initial promises. It promised universal coverage -- but the Congressional Budget Office estimates it will cover only about 40 percent of the uninsured. It promised lower premiums for families -- but premium costs for families look likely to broadly increase. It promised lower health costs for government -- but those costs are not coming down. The Health and Human Services actuaries expect health inflation to return strongly in 2014, largely because of Obamacare.

"By going about this large change themselves," says Yuval Levin of the Ethics and Public Policy Center, "the Democrats are taking ownership of the health care system, and that is a system that most people don't much like and will probably like less in the next few years. ... So I'm not inclined to think that the public will take this as an addictive drug."

This presents Republicans with a political opening. But it is equally true that politics -- the securing of a Senate majority and the presidency -- is their only option to repeal and replace Obamacare. There are no shortcuts. The task will require a substantive critique, effective political strategy, democratic patience and market-oriented policy alternatives that deal with pre-existing conditions and cover more of the uninsured.

The task will not be accomplished by hyperbole, shallow analysis, political breath holding and extravagant, immediately disappointed pledges of repeal. And oh, by the way, it also doesn't help to dismiss millions of your fellow citizens -- some in genuine need -- as welfare state junkies.

Michael Gerson's email address is michaelgerson@washpost.com.

2013, Washington Post Writers Group

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