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.