Whether or not you think Obamacare is "doomed" (and I realize many here will take issue with that characterization), this column in Foreign Affairs should be required reading for the points it makes about America's welfare system, and how government is run in this country in general.
Sidestepping the braindead and very limited American political debate, where the left defends the ACA as a bold new social initiative, while the right equates it with Marxism, Kimberly Morgan correctly identifies the broken nature of the current system, of which the much-maligned healthcare.gov website is just a symptom.
But the fact that the White House is having trouble implementing Obamacare also should not come as a particular surprise. It is not that the Obama administration is especially incompetent. Rather, the program it is charged with executing is a complex public-private hybrid that has no real precedent elsewhere in the world. The blend is purely American: Policymakers in the United States have a history of jerry-rigging complicated programs of this sort precisely because they have little faith in government. The result is a self-fulfilling prophecy that fuels only deeper public cynicism about the welfare state.
The real source of Obamacare’s current problems lies in the law’s complexity. A straightforward way to assure coverage would have been to extend an existing, well-worn program to more people. This is how most other countries guarantee health insurance. In the British National Health Service, there is little that beneficiaries need to do in order to receive health insurance, as all residents are automatically entitled. Other countries rely on private intermediaries that provide insurance -- nonprofit insurance funds in Germany or Switzerland, for example, or a mix of proprietary and nonprofit insurers in the Netherlands. Even in those instances, benefits packages and entitlements are highly standardized, making these health-care systems relatively uncomplicated from the standpoint of beneficiaries.The real villain here is not some website contractor but the American political system itself — the ideology, now almost universally accepted by both Republicans and Democrats, that says privatization is always more efficient and less costly then government.
In the United States, political antipathy to government programs precludes this kind of straightforward administrative solution. Faced with such hostility, policymakers regularly rig up complex public-private, and often federal-state, arrangements that are opaque to the public, difficult to administer, and inefficient in their operation -- what Andrea Louise Campbell, a professor of political science at the Massachusetts Institute of Technology, and I describe as a Rube Goldberg welfare state -- because of the complicated way in which it achieves even basic tasks -- and what the political scientist Steven Teles aptly labels a “kludgeocracy.”
America's distrust and hatred of government, Morgan argues, has been a self-fulfilling prophecy. The insistence on "market-based solutions" has somewhat ironically led to a byzantine system of intermeshing private and public interests that often ends up being more costly, more bureaucratic and delivers far worse outcomes than those in other countries that simply have straightforward public services.
I would add another component to this critique: greed. The American insistence that profits must be preserved at all costs, even when it comes to people's lives, is what has helped lead us down this road. Today, we see it everywhere, starting with the flailing healthcare.gov website, which tries to integrate multiple private and public systems so that Americans can obtain subsidies in order to sign up for a mandated plan to buy private insurance in order to get access to healthcare, something other countries simply provide to their citizens.
Or consider the sprawling shadow government of private contractors like Booz Allen Hamilton that steal billions from public coffers while inventing ever more perverse ways to spy on the American people. What about the private prison system that bribes judges to lock kids up and make them modern day slaves in a low cost labour scheme? Or the American Legislative Exchange Council, where public policy has been hijacked by multinational corporations in a matchmaking scheme with state legislators dreamed up by the Koch Brothers?
Of course, some might criticize Morgan for being impractical; we are stuck within the current system, so why not try to deliver better outcomes using the tools at hand? The problem is that over the long term, all "Reaganomics with a human face" does is entrench the current system. As Slavoj Žižek points out in this brief and quite entertaining lecture, First as Tragedy, Then as Farce, the modern center-left often ends up simply greasing the wheels of inequality by sanding down the rough edges. Over the long run, an intelligent critique coming from outside the bounds of mainstream American discourse is what is desperately needed.