Opinions columnist, 2007-2022

Supporters of Obamacare are celebrating that the law is not an unmitigated disaster, just a mitigated one.

As enrollment closed (for most) on March 31, the system passed 7 million exchange sign-ups. What some are taking as a triumph of governmental competence was actually an emergency rescue by private-sector volunteers after a laughable failure of government to construct and run its own system. This has hardly been a confidence-builder when it comes to public faith in bureaucracy. But never mind.

And never mind that the actual goal was not 7 million exchange sign-ups; it was health insurance enrollments, which are likely to be significantly fewer. And never mind that the number of the previously uninsured seems a remarkably small portion of these sign-ups — well under half. (Health wonk Bob Laszewski estimates that only about 27 percent of Americans eligible for Obamacare subsidies have enrolled in the system.) And never mind that, even including the Medicaid expansion, the most optimistic estimates of reductions in the number of the uninsured are much less than what the Congressional Budget Office projected before the rollout began. And never mind that all these decreases in the uninsured seem small in comparison to the amount of money spent, displacement caused and political capital expended.

And never mind that the proportion of younger and healthier enrollees to those with preexisting conditions is still being determined and that many analysts expect double-digit insurance premium increases in many state exchanges (particularly those with limited insurance competition). And never mind that health-care cost inflation has suddenly spiked to a 10-year high.

The Obama administration is pausing to bow at mile two of a marathon. And supporters, naturally, are grateful for some reason, any reason, to cheer. But the whole story of Obamacare has been a cycle of overpromising and disappointment. And advocates seem determined to continue it.

Still, some conservative critics of Obamacare — those advocating repeal and, well, nothing — are inhabiting their own ideological daydream. President Obama did not invent a right to health care, just a right to a highly regulated form of health insurance. Americans had jury-rigged a system long before. Under a federal law from the 1980s, hospitals taking Medicare can’t deny emergency treatment to people based on their ability to pay for it. Medicare and Medicaid provide insurance to the elderly and poor. This combination of emergency-room care and health entitlements amounts to a guarantee of a certain kind of health care — often provided late in disease progression, after a long wait in line, by harried, overwhelmed doctors trying to navigate in (or game) a system of wage and price controls.

Conservatives need this to sink in: America already has a right to a certain minimum of health treatment, which is not going away. It is an expression of compassion and decency. But it is not well-designed or efficient. And it leaves millions of people with an inferior quality of care.

Obamacare seeks to replace this patchwork approach with a cumbersome system that covers relatively few of the uninsured at a high social and economic cost. Reform conservatives — the term that an intellectual movement advocating policy alternatives seems to have coalesced around — also generally believe that the extension of health insurance coverage is superior to the entitlement/emergency room system. But the Burr-Coburn-Hatch bill, and the proposal advocated by health policy expert James Capretta, would use a much simpler mechanism of refundable credits to enable more people to buy catastrophic health-insurance plans — which are both more affordable and put some downward pressure on the consumption of routine health services. (These plans would also cover people with preexisting conditions.)

Both the left and (responsible portions of) the right want to solve a problem that leaves tens of millions without health insurance. The left’s answer, embodied in Obamacare, is to tell sellers what to sell and buyers what to buy, and to subsidize buyers for the purchase of products they would not otherwise want and to penalize them for not doing so. The right, as Yuval Levin, editor of National Affairs, puts it, “hopes to achieve efficiency by setting off a massive competition among private players to provide people with the product they want at the lowest possible price. And it wants to use public resources to make achieving that goal attractive to private players, by subsidizing people to function as consumers.”

Conservatives have serious alternatives to Obamacare. But the only way to credibly offer them is to recognize that access to some form of health care is a right in the United States — and was so, long before Obamacare.

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