In America's Bitter Pill: Money, Politics,
Backroom Deals, and the Fight to Fix Our Broken Healthcare System (Random
House, 2015), Steven Brill summarizes the history of federal attempts over the
past 50 years to provide national health insurance. The movement towards the plan that became
known, first with disparagement, then with the approval of Obama himself, as
Obamacare, was gradual and evolutionary.
It was two-pronged. There was the
need to provide coverage for citizens too poor to pay for their own insurance,
or whose employers did not provide coverage.
Then there was the desire to control the costs of health care in
America, the single largest expense by far charged by any industry in the
United States. Because the healthcare
industry could afford to pay for a powerful and effective set of lobbyists, and
for political reasons, discussions of universal health care coverage tended to
focus more on coverage than on controlling and cutting costs.
Brill
describes the process by which senators and members of the new Obama
administration worked on the development of a proposal for universal
healthcare. It was a process of
political wrangling, rivalries, informed decisions, disagreements, compromise, crossed
signals, incompetence, and more. What is
surprising is not the resulting massive and confusing and self-contradictory
set of policies known as Obamacare, but the fact that any proposal was
completed and passed at all.
The political
divides that informed and shaped the process are deeply disturbing and despair
inducing.
When
the actual creation of Obamacare began, the President called on appropriate
advisors and congressional committees to develop the proposal. Occasionally he provided directions and
provided public comment. Behind the
scenes, divisions among his advisors, miscommunications, and poorly conceived
planning caused numerous problems. Often
Obama was unaware of the disagreements among his advisors because he expected
them to tell him what their conclusions were, not how they disagreed with one
another. At key moments a firmer set of
directions from the President could have made the work easier. The process overall was one that seems to
have been shaped by disorganization and political shenanigans.
Although
the President wanted his proposal to reduce costs, the intense power and
lobbying of insurance companies, some of which colluded with hospitals to set
prices and policies, pretty much shut down any hope of progress in this area. Instead most of the work focused on how to
provide more or less universal coverage for American citizens.
The
rise of the Tea Party in 2008 did not help matters. Focusing on such concepts as “death panels”
and “government control” and so on, Tea Partiers induced deep paranoia among
congressmen and senators running for reelection. Just when the Obama administration believed
it had secured the necessary support to pass the proposal, the Tea Party
movement made it seem possible or even likely that Obamacare would fail.
Brill
credits Obama’s commitment to universal health care but finds fault with how
the plan was developed and implemented.
Government incompetence and mendacity resulted in a largely
malfunctioning web site that threatened the survival of Obamacare—four government
agencies vied in one way or another for control of the implementation, these
agencies communicated poorly if at all with each other, they produced
unrealistically rosy and inaccurate projections of their progress towards
implementation, and in the end programmers from Google had to step in and bring
the system up to speed, in essence saving Obamacare, though to my knowledge
they have not received much credit for their work.
