Douthat’s Sunday column is a pointed critique of the federally-administered Affordable Care Act rollout of insurance exchanges. Disregarding one ridiculous paragraph comparing it to the invasion of Iraq (really, Ross?), it’s very much worth reading for both opponents and advocates of the health reform law.
Here is a segment (emphasis in bold mine):
But if the fix-it effort moves too slowly, it’s possible to envision a worst-case scenario unfolding. If the Web site doesn’t work soon, even liberals concede that the mandate would have to be delayed, because you can’t very well fine people for failing to buy a product they can’t access. And that combination — a hard-to-navigate online portal and no penalty for staying uninsured — could effectively discourage all but the most desperate customers from shopping, which in turn would create an unsustainably expensive insurance pool, driving prices up and driving people away, and potentially wrecking the entire individual insurance market in short order.
If this happens, there will be a lot of schadenfreude on the right at the spectacle of technocratic failure. But the wreck of the exchanges may actually be worse for conservative policy objectives than a more successful rollout would have been.
That’s because while conservatives think the Obamacare exchanges are overregulated and oversubsidized, they are actually closer to the right-of-center vision for health care reform than the Obamacare Medicaid expansion, which is happening no matter what transpires with Healthcare.gov. So if the exchanges fail and the Medicaid expansion takes effect (and, inevitably, becomes difficult to roll back), we’ll be left with an individual market that’s completely dysfunctional and a more socialized system over all.
That first part of the last paragraph has been a point repeated ad-nauseum by non-conservatives. The individual exchanges established by ACA are primarily an exercise in arranging a mixed-marketplace, originally written to be entirely state-based, to provide private health insurance coverage for the uninsured. The second part of that last paragraph quoted has fallen to the wayside as technical incompetence has dominated the headlines, but it’s incredibly important.
One of the counter-points to Douthat’s earlier throwaway line about the ACA and liberalism was that the Medicaid expansion is unrelated, though not without it’s own problems, to the success of the exchanges. Further, that a failure of the latter would be difficult to predicate the end of liberalism as it exists in popular political ideology if the former worked at the same time. Which is to say, that a fully-functioning state-federal program of universal low-income health coverage — operating much more cheaply than other insurance sectors — at the same time that a complicated federal attempt to construct a private insurance exchange fails may not be the victory conservatives should want. Especially if it is the case that elected Republicans would like to attempt a similar framework for a privatized Medicare.
Douthat goes on to write that such a future wouldn’t leave liberals pushing for single-payer (not that it wouldn’t be raised), but rather a more pragmatic movement towards lowering the ceiling for Medicare and raising the floor for Medicaid. Why? In that hypothetical future it would be more-centralized government programs that are proven to provide the greatest coverage for the lesser per-person price, not private markets with varying degrees of government regulation. For that reason conservatives should, perhaps, be rooting for the success of the individual markets and hoping beyond reason that the Medicaid expansion fails.