There’s a scene in P.G. Wodehouse’s Right Ho, Jeeves where Bertie Wooster receives a telegram from his fearsome Aunt Dahlia that reads: “Come at once.” Bertie is puzzled. He reflects and agonizes and sends several follow-up telegrams requesting more lucid instruction. Finally he shows the cable to his perceptive manservant Jeeves and asks him to translate.
“I think Mrs. Travers wants you to come at once, sir,” Jeeves says.
Sometimes it seems like the liberal base of the Democratic Party has a similar problem. They’ve been saying for decades: “We want Medicare for all.” Senior Democrats furrow their brows and ruminate, they fret about public opinion and blue dogs, they devise independent payment advisory boards and state-run insurance exchanges. Meanwhile the activists are rolling their eyes. “No, Medicare for all. It’s not that hard…”
Turns out the activists may have a point. The L.A. Times triumphantly reported this week that 9.1 million people who were previously uninsured have signed up for health insurance thanks to Obamacare. But of that total, 4.5 million have been enrolled through Medicaid and 3 million are 26-year-old “children” who opted to remain on their parents’ plans. That means that, as John Sexton pointed out, you could have achieved 7.5 million of that 9.1 million by just expanding Medicaid and opening young adults to their parents’ insurance. A plurality of that success comes from expanded Medicaid—which isn’t a huge leap from Medicare-for-all. It’s easy to dump people on the government rolls, after all.
For years, the liberal “path to single-payer” usually involved something similar—expanding existing government programs to provide more people with more care. In 2003, President Bush capitulated to Democrat demands and added Medicare Part D, which paid for seniors’ prescription drugs. In 2009, President Obama signed an expansion of the State Children’s Health Insurance Program (SCHIP) to cover 4 million more children. But with Obamacare, Congress decided to try something different. It wanted to shift the direction of the private health insurance market, and in order to do so, ended up creating reams of new regulations and bureaucracy that are superfluous to achieving its goals.
Let’s be clear: None of this is an argument in favor of Medicare for all, which would starve innovation, shrivel the health care market, and add more sticks of dynamite to an entitlements system already primed to explode. But in retrospect, the grand complexity of Obamacare must seem absurd, even to liberals. There was a computer game that was popular when I was young called The Incredible Machine. Essentially a glorified physics lesson, the player had to place everyday items in a way that would cause a chain reaction and achieve a goal: a basketball bounces over a switch, which activates a conveyor belt, which moves an anvil, which breaks the fish tank. Obamacare is like this, except there’s thousands of pieces, they’re all moving, the basketball is deflated, the conveyor belt is broken, and, by the way, why don’t we just break the fish tank with a hammer instead?
Following the L.A. Times numbers, news broke this week that the groaning contraption had managed to enroll 7.1 million people in private insurance (not counting those signed up for Medicaid or their parents’ plans). This allowed the president to spend several days gloating and dispensing sententious advice to Republicans. But the 7.1 million number is useless. We have no idea how many of those have paid their premiums. We have no idea how many were previously uninsured. We have no idea how many are young and fit; too few and you could still see adverse selection in the risk pools, resurrecting the ghastly prospect of a death spiral.
That being said, I think the law’s opponents made a tactical error here. They spent the past four months taunting the administration over the website and predicting anemic enrollment. Some conservatives even convinced themselves that Obamacare’s failures might kill liberalism. They were so focused on a single rusty gear—the exchanges—that when that gear moved just a bit, it allowed the president to declare victory. The larger Obamacare machine was forgotten.
And that machine is still falling apart. Health insurers are planning enormous premium increases for later this year. Another 500,000 grandfathered health insurance plans will be canceled in two years. The employer mandate kicks in for small businesses in 2016. The excise tax on so-called Cadillac insurance plans, which has labor unions spitting nails, activates in 2018. Even the 7.1 million enrollees only amounts to half of what the CBO had projected.
Obamacare will continue to sputter and malfunction. Let’s just make sure we explain that in full.