To follow what’s happening with the new health care law
right now, you have to understand that for all the deep divisions on the issue,
there’s actually a real bipartisan consensus about how the American health care
system ought to be reformed.
Or rather, there are two of them – a dishonest consensus
among politicians and an honest consensus among people who study public policy
for a living.
The politicians’ consensus is that health care reform
shouldn’t alter or disrupt the way the majority of Americans get their
insurance today. This is President
Obama’s official position on the issue: again and again throughout the fraught
2009 debate, he reassured voters that if they liked their existing health care
plan , his bill wouldn’t prevent them from keeping it. It’s also the official position of his
Republican critics, who have consistently attacked Obamacare for undercutting
that presidential promise – for slashing Medicare, for driving up premiums and
for threatening the employer-provided insurance status quo.
The policy consensus, though, is that the status quo is
actually the problem, and that it deserves to be threatened, undermined and
replaced as expeditiously as possible.
Wonks on the left and right disagree on what that replacement should
look like. But they’re united in
regarding employer-provided coverage as an unsustainable relic: a burden on
businesses, a source of perverse incentives for the health care market and an obstacle
to more efficient, affordable, and universal coverage.
Yet woe betide the politician who dares to publicly
agree. That’s what John McCain
discovered in 2008, when he proposed a sweeping reform that would have
eliminated the tax incentives that undergird employer-provided coverage. Conservative policy types loved the idea (as
well they should, being responsible for it), but it cost McCain dearly: the
Obama campaign used it to attack him, relentlessly and effectively, as an enemy
of the way most middle-class people get health insurance, and thus of the
middle class itself.
These attacks, in turn, constrained the Obama White House
when it came time to design its own health care reform. Obamacare has an unwieldy, Frankenstein’s
monster quality in part because the law is trying to serve both consensuses at
once. The core of the bill, the
subsidies for the uninsured and the exchanges where they can purchase plans, is
designed to offer a center-left alternative to the existing system. But much of the surrounding architecture is
designed to prop up existing arrangements – and in the process, protect Obama
from exactly the kind of criticisms he one levied against McCain.
Or at least, it was designed that way. But then came last week’s announcement that
the White House would be delaying, for a year, the new health care law’s
employer mandate, which required businesses with more than 50 employees to
offer health coverage of face a fine.
Republicans reacted by hyping the announcement as a sign
that the entire law is unraveling, Democrats by minimizing the significance of
the move. But the more telling reaction
came from the policy world, where conservatives and liberals took a break from
their usual disagreements to agree that the White House and Congress should
just scrap the employer mandate altogether.
That’s because the mandate is mostly just a political device
designed to hide the full cost of the bill and discourage employers from
eliminating employee coverage too quickly once Obamacare’s new exchanges are up
and running.
Like many politically minded regulations, it risks perverse
economic consequences – delayed hiring, reduced work hours – which explains why
the White House decided to punt it to 2015.
But the mandate’s outright abandonment is more desirable, because that
would have a clarifying effect on the entire health care debate.
Right now, both parties are still pretending that H.R.
departments will go on doubling as welfare states forever. If it dropped the employer mandate, the Obama
White House would be fully committed to a more disruptive future, in which
exchanges and subsidiea gradually replaced the employer-based system. And since those exchanges and subsidies are
going to be implemented by this administration no matter what – barring a Martian
invasion or a zombie apocalypse, at least – the sooner we find out if they
really work and what they really cost the better.
As Avik Roy, one of the mandate’s conservative critics,
wrote last week in Forbes, “if you like Obamacare, and you want it to work, you
don’t need the employer mandate.” And if
you don’t like Obamacare (as Roy doesn’t), and don’t expect it to work, then
all the mandate does is delay a necessary reckoning with the new system’s
flaws.
Either way, the White House’s decision is a step toward
honesty in policymaking. It takes us a
little closer to a world where politicians of both parties actually level with
the public, and acknowledge that employer-provided health insurance is an idea
whose time has passed.
Excerpted from "A Hidden Consensus on Health Care" by Ross Douthat in The New York Times on Sunday July 7, 2013.
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