That’s a bit personal for me, since I was one of Obamacare’s most committed critics. Obviously, I failed to convince the rest of you. This seems an apt time for a bit of self-reflection: Was Obamacare really as bad as I thought it was going to be?
In a lot of ways, the answer is no. But that’s often because it wasn’t as good as my opponents expected, either, which I think most would readily admit.
My critique boiled down to four main points: First, I doubted we would improve our overly complex, balkanized health-care system with yet another major program that would make it even more complicated. Second, I feared committing more than $100 billion to new spending every year, at a time when we hadn’t even figured out how to pay for existing entitlement programs. Third, I worried that having the government subsidize even more of our medical bills would lead to price pressure, particularly on pharmaceuticals and medical devices, which in turn would reduce incentives for innovation. And fourth, I simply didn’t believe many of the claims supporters were making — explicitly or implicitly — about Obamacare dramatically reducing health-care costs or bankruptcies or infant mortality, or improving life spans.
Eleven years on, that first worry seems overblown. Our system is still a Rube Goldberg-esque kludge, but not noticeably more so than in 2010. As for the effect on innovation, well, Pfizer and Moderna just brought two new cutting-edge vaccines to market in less than a year. And while I’m certainly worried about a fiscal crisis, Obamacare is the least of our worries, since no politician in either party appears to believe that government spending and government revenue have any relation to each other, or ought to.
On the fourth point, however, I think that my predictions have largely been vindicated. And that this is one major reason the others haven’t been.
Obamacare’s supporters claimed that tens of thousands of people were dying every year because they didn’t have health insurance, which implied that by 2019, our overall mortality rate should be substantially lower than it had been in 2009, with a noticeable kink around 2014. Instead, mortality rates, which had been trending downward, leveled off around that time.
Obamacare’s supporters talked a lot about reducing health-care costs, or at least the rate at which they were growing. Sadly, no.
Partly that’s because those claims were always oversold; research performed in the years since suggests that offering people health insurance has more measurable impact on their financial health than their physical health, and that medical bankruptcies may be driven less by medical bills than by income loss, a problem Obamacare doesn’t address. But there’s another reason neither those optimistic promises nor my pessimistic prophesies bore fruit: We were all wrong about an even bigger question.
In 2011, Doug Elmendorf, head of the Congressional Budget Office, testified that by 2021, 24 million people would be buying their insurance on the Obamacare exchanges. It’s fair to say that both Obamacare’s friends and foes assumed the number would be at least that high, if not higher. In reality, the most recent data suggest it’s half that.
The Medicaid expansion has been more in line with projections, but it, too, is smaller than expected, in part because the first time the Roberts court rescued Obamacare, it ruled that the federal government had to let states opt out of expanding their programs. And that, in turn, has lessened the pressure for the government to exert more stringent pressure over health-care delivery or prices. Most of Obamacare’s gestures in that direction were less effective than hoped, or died on the vine.
That’s not to say Obamacare did nothing; the percentage of Americans who are uninsured has fallen from 16.7 percent in 2009 to 9.2 percent in 2019. That’s a substantial achievement, which even the program’s harshest critics should acknowledge. But even its most zealous boosters should be willing to admit that the program the Supreme Court saved this week is far from the revolutionary transformation its architects envisioned.