The Big Kludge

by Paul Krugman,

The good news about HealthCare.gov, the portal to Obamacare’s health exchange, is that the administration is no longer minimizing its problems. That’s the first step toward fixing the mess — and it will get fixed, although it’s anyone’s guess whether the new promise of a smoothly functioning system by the end of November will be met. We know, after all, that Obamacare is workable, since many states that chose to run their own exchanges are doing quite well.

Imagine, now, a much simpler system in which the government just pays your major medical expenses. In this hypothetical system you wouldn’t have to shop for insurance, nor would you have to provide lots of personal details. The government would be your insurer, and you’d be covered automatically by virtue of being an American.

Of course, we don’t have to imagine such a system, because it already exists. It’s called Medicare, it covers all Americans 65 and older, and it’s enormously popular. So why didn’t we just extend that system to cover everyone?

The proximate answer was politics: Medicare for all just wasn’t going to happen, given both the power of the insurance industry and the reluctance of workers who currently have good insurance through their employers to trade that insurance for something new. Given these political realities, the Affordable Care Act was probably all we could get — and make no mistake, it will vastly improve the lives of tens of millions of Americans.

Still, the fact remains that Obamacare is an immense kludge — a clumsy, ugly structure that more or less deals with a problem, but in an inefficient way.

And the main reason that is happening, I’d argue, is ideology.

[For example,] the assault on Medicare is really about an ideology that is fundamentally hostile to the notion of the government helping people, and tries to make whatever help is given as limited and indirect as possible, restricting its scope and running it through private corporations. And this ideology, at a fundamental level — more fundamental, even, than vested interests — is why Obamacare ended up being a big kludge.

For now, the priority is to get this kludge working, and once that’s done, America will become a better place.

In the longer run, however, we have to tackle that ideology. A society committed to the notion that government is always bad will have bad government. And it doesn’t have to be that way.

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