Young: Obamacare sought to do too much
At least for now, the Affordable Care Act looks less like the historic achievement of the Obama presidency than the fiasco of a political lifetime: First the website woes, now the insurance policy cancellations that have led the president to apologize for his "If you like your insurance, you can keep it" promise.
In coming months, the problems may be partly resolved, and the glut of bad news may be balanced by success stories. But the health care wars will go on because they reflect not only conflicts of cultural values, but also the paradoxes of modern medicine. In the face of the conflicts, any attempt to reform American health care must have one thing Obamacare lacked: humility.
Obamacare's libertarian and conservative detractors generally agree that the American health care system -- an often dysfunctional public-private hybrid -- needs reform. But the reforms they advocate involve freeing up the market and reducing insurance coverage for non-catastrophic care. If patients bear more out-of-pocket expenses, the argument goes, they will be more likely to negotiate lower prices or reject unnecessary procedures.
Businessman David Goldhill, author of the book, "Catastrophic Care: How American Health Care Killed My Father -- And How We Can Fix It," asserts that this would make economic sense and improve health care by reducing overtreatment, the burdens of which he blames for dangerous levels of error.
Some of Goldhill's proposals make sense (though critics note that the Singaporean system, which he praises, combines fee-for-service practice with government price controls). But a shift toward consumer-driven care would create its own horror stories: tales of loved ones "killed" by deciding against a costly test or treatment. One person's unnecessary test is another's preventive medicine.
Virtually any health care model has pluses and minuses; it's a matter of choosing which ones we prefer. Americans' attitudes on the subject are closer to confusion than consensus. In a CNN poll last May, only 43 percent endorsed Obama's health care law -- but another 16 percent favored more, not less, government control. Other surveys find that two-thirds consider health care a right and close to 90 percent believe health insurance should be available to all. Yet people are split on whether medical coverage should be an individual responsibility or a government guarantee; backing for higher taxes to support universal coverage varies from 36 percent to 57 percent, depending how the question is framed.
The difficulty of these choices is compounded by the fact that medicine, and its progress, poses some hard decisions. Many conditions that, not long ago, would have led to disability or early death can now be cured or managed. The gains in health and longevity have been vast: Death at 70, once a normal fact of life, is now seen as premature. But these gains also cost vast amounts of money; moreover, expensive treatments may offer minimal value or even do harm. (Modern medicine's accomplishments lead us to overrate its omniscience.) When should intervention be rejected as too costly, and on what basis? Ability to pay? Doctors' opinions? Patient preference? Expected length and quality of life?
Given these questions, the best way to tackle reform was not a grand plan but a flexible one on a state-by-state basis. Even the federal government could have addressed the problem of the uninsured in a more modest way than an insurance overhaul: For instance, expanding Medicare to people uninsurable due to pre-existing conditions. While there is little appetite for Obamacare's repeal, there may still be time for reform in those directions.
Cathy Young is a regular contributor to Reason magazine and the website RealClearPolitics.