Do Obamacare’s three “mores” spell long-term failure?

Ross Douthat has been doing some thought provoking writing about Obamacare of late. In his latest post, he discusses how Americans might respond to what he terms the law’s three “mores”: that the insurance it offers “will be more expensive, more subsidized and more comprehensive than what was previously available on the individual market.”

Do they spell long-term failure? Douthat does not say that they will with certainty, but it’s the question he raises.

This is why the law’s critics believe Obamacare might be a long-term failure even if it survives its launch troubles and works on its own terms for a while. It’s not about the good things the reform delivers: those are real enough. It’s about whether there are too many other goods, for too many people, that the law’s three “mores” end up crowding out.

Maybe! But I think the pundits’ tendency to view the long-term fate of the law as a “success” or “failure” is a symptom of short-term political thinking. Right now, and for the last four years, it was entirely reasonable to think of the law’s fate as a success or failure. We’ve been in a perpetual struggle over this very dichotomy. Elected Republicans (not all, but most) have fought for defeat, reversal in the courts, repeal, defunding, and certainly tried in every way possible to sow the seeds for troubled, if not failed, implementation. Meanwhile, elected Democrats (not all, but most) have fought for success, legal legitimacy, to maintain funding, and for implementation.

But this has all occurred in an environment unlike one we’re likely to see a year from now and beyond. To date, the features of Obamacare that have been implemented, though important, are relatively minor compared to what’s now being attempted. Once the exchanges are functioning (presuming they do function) and Medicaid expansion takes hold (in states that have accepted it), things will be different. Tens of millions of people will depend on the law in ways not all of them even realize today. Likely most people will know someone whose insurance depends on Obamacare. Businesses will have reorganized and health care providers will have retooled in ways that depend on the law as well.

This will all make a big difference. People won’t want to lose their coverage or part thereof. People won’t want their friends and relatives to lose coverage. People will be very concerned about changes of any type, just as they are today. Businesses and health care providers will not want the landscape to be dramatically reshaped anytime soon. Status quo bias is strong, and there will be a new status quo. We know this. This very fact is what gives comfort to supporters of the law and what drives the desperate attempt by opponents to kill it before it fully launches.

That’s not to say people will uniformly like the cost of coverage. I fully expect many, if not most, will think health care is too expensive. We already think that, and have for years. I do think this will eventually give rise to further reform proposals and be a topic of campaigns. But it will all be in the context of Obamacare, upon which many depend.

Therefore, what I expect is not a conversation about “success” or “failure” or — in time — about “repeal,” but about how to incrementally change the law to start to take better control of costs.

After all, Medicare has a cost control problem, has for decades, and it’s not ever been close to being repealed. The biggest, recent change has been to expand it, adding a drug benefit. Yes, we also get payment reforms. They’re not deep enough, to be sure, but they’re a far cry from repeal or restructuring. Though restructuring may be what we need, it’s a heavy political lift to achieve it.

Or look at Massachusetts. There health reform like that occurring at the national level has not tamed spending. There’s hardly a cry to reverse the coverage law, though. Instead, there’s an effort underway to add to it in ways that may better control that spending.

On the whole, this “success” vs “failure” idea is short-sighted, and soon will be out of date. Indeed, there’s a policy risk in continuing such rhetoric. So long as Republicans couch their reform ideas in the language of “repeal,” Democrats have no choice but to resist. They own the law and they’re not going to let the opposition steal it away.

Ironically, many conservative reforms could easily fit within the framework of Obamacare, and likely would appeal to moderate Democrats. Once we get beyond “repeal,” broad, bipartisan reform that more fully addresses at least some of Douthat’s three “mores” may be possible.

Notice, I did not say “likely.” After all, the partisan divide is still wide and campaigns are not likely to be won on a message of kumbaya.


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