Just a few weeks ago, on the heels of the Tea Party’s disastrous shutdown of the government, pundits were predicting a sea change in American politics. Republicans were on the run, while Democrats were looking to recapture the House and revive a can-do, muscular liberalism. Oh, how things have changed! Now the conventional wisdom is that the various snafus in the rollout of Healthcare.gov have reversed the political dynamic. On Fox News, Charles Krauthammer and Bill O’Reilly crow about the “end of modern liberalism,” the New York Post declares an “Obamacare Overreach,” and Congressman Paul Ryan (who, as my colleague Lee Fang points out, once quietly requested Obamacare cash for his own district) brays on about how Americans are witnessing—and rejecting—“big government in practice.” Even mainstreamers like The New York Times’s Ross Douthat, invoking Jonathan Rauch’s tired, Clinton-era jeremiad against the size of government, blame Obamacare’s failures on bureaucratic sprawl, because “government spends and regulates so much.”
It’s a nice parable, full of the tidy parallels that make the No Labels crowd swoon: as Republicans have pushed their monomaniacal hatred of government too far, so Democrats have fallen into the hubris of thinking that big government can solve everything. It’s also total bullshit.
At this point, we don’t know if the Affordable Care Act will eventually succeed and endure, and anybody who tells you it will or won’t is indulging in ideological wish fulfillment. What does seem clear is that unless circumstances change, it will fall short of its original goal of insuring 27 million Americans by at least 5 million people—and perhaps many, many more. These shortcomings, however, are a result of government being too small—too clipped, constrained, underfunded and underpowered—to achieve Obamacare’s policy aims, not vice versa.
Here’s how the Affordable Care Act ran into trouble. The drafters of the law planned to insure 16 million poor and near-poor Americans through an expansion of Medicaid. As a carrot, they fully funded the expansion at the outset and funded 90 percent of it by 2020—a formula much more generous than what’s currently offered. As a stick, they designed the law so that states that refused the expansion would lose their Medicaid funding. When the Roberts Court upheld the individual mandate (the requirement that Americans purchase health insurance or face tax penalties), it also broke that stick, allowing states to opt out of the expansion without penalty. Since then, twenty-one states, all of them controlled by Republicans, have done just that. As a result, about 5 million Americans, the majority of whom are people of color in the South, will fall into a coverage gap. They are ineligible for Medicaid and will be required to purchase insurance. At the same time, they are too poor to qualify for the ACA’s subsidies. But nota bene: the plight of these poor Americans is not a result of any flaw in the original law; it’s due to the Roberts Court’s gutting of one of the law’s crucial levers and the wave of GOP cruelty politics that ensued.
It’s a similar story with the much derided federal exchange. Yes, the IT whiz kids in the administration failed to live up to expectations. And yes, the president made a mistake when he claimed—in a foolish attempt to rhetorically minimize the law’s impact—that people who buy insurance on the exchange can keep their plan if they like it. But those missteps—one bureaucratic, the other political—aren’t the main problems with the federal exchange. It’s that Healthcare.gov was never supposed to be the focal point of the ACA.