To oversimplify just a bit, Mike’s argument is that the website “glitches” we’re seeing are rooted not so much in mishandled software contracts but political philosophy. The structure of Obamacare, he says, reflects a “neo-liberal” paradigm which sees government social insurance as best provided by private entities, administered by the states, heavily means tested, and crafted to maximize consumer choice. He calls this “Category A” social insurance, in contrast to New Deal/Great Society-type “Category B” programs that are universal in nature, compulsory rather than voluntary, and delivered directly by the federal government. The latter programs tend to be simpler, better-administered, more cost-effective, and popular; the former more complex, error-prone, and frustrating to use.
While these categories aren’t water-tight (AFDC was a means-tested, state-administered New Deal-era program) they are useful enough, and Mike’s analysis about the dangers of built-in complexity in program design aligns with much of Steve Teles’ brilliant diagnosis of American government “kludgeocracy.”
But as the editor of the magazine whose founder coined the term “neo-liberal” to describe the publication’s philosophy, I’d like to make clear that while the Washington Monthly has very much supported Obamacare—in part because we understand that it was the best healthcare legislation that was politically achievable at the time, in part because we believe it can be made to work and do a world of good—what we have consistently advocated for some years now is a “Category C” version of reform that is actually more to the left than where most liberals are. Mike and folks like him want single-payer health care. We want single-delivery health care.
That is to say, we’ve sketched out here and here a plan for a healthcare system modeled on the VA, in which the government doesn’t just provide universal insurance but actually runs the hospitals and clinics. As the author of these pieces, Phil Longman, likes to say, it’s 100 percent socialism, but a homegrown variety that doesn’t rely on sentences that begin “In Sweden they..” for proof of concept, because our own VA, despite its many publicized faults, unquestionably delivers the overall best-quality, most cost-effective healthcare in America.
Of course we recognize the unlikelihood of ever getting political support for such a government-run system. So in 2011 we turned the basic idea into a plan to transform Medicare from a fee-for-service model to one that requires beneficiaries to choose to get their healthcare services from competing non-profit systems—be that the VA itself, or Kaiser-Permanente, or other national-in-scope organizations that follow VA-like protocols of coordinated care, open-source data systems etc. We make the case that this plan could not only solve the government’s long-term fiscal problems by getting control of healthcare costs while providing better-quality health care to America’s seniors, but that it could actually work politically—though I must admit we have yet to see a mass uprising in favor of our idea.
My point, however, is not so much to argue for the political expediency of this vision than it is to simply get liberals to expand their minds, claim this territory of reform as their own, and factor it into the discussion as the debate about healthcare reform proceeds.
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