The Real Beneficiaries and Victims of Obamacare
The success or failure of Obamacare is often looked at in terms of "winners" versus "losers."
I think the bottom line here is that the "winners" greatly outnumber the "losers" in general and in the individual market in Obamacare, but the media and political math is different from the actual math. A significant minority of "losers" or self-perceived losers and a few high profile bad outcomes...are more than enough to cause real political problems.
Kaiser is an organization that does research on health policy issues, but I would wager that even the learned people at Kaiser have no real idea at this point whether there will actually end up being more "winners" than "losers" under Obamacare compared to the health insurance system that preceded it, much less that the winners will "greatly outnumber" the losers. With Obamacare, there are just too many known unknowns as well as unknown unknowns.
But let's just stipulate, for the sake of argument, that Altman knows a great deal about number crunching and health insurance. What he may not know so much about is how people might feel about having been lied to by the president, even if some of them might have ended up as "winners" paying lower premiums. He may also not know how some people feel who used to be economically independent but who now need the government subsidies in order to afford their compulsory health insurance: are they "winners" too, or do some perceive the change as a blow to their self-respect? Do some "winners" get angry on behalf of their friends and relatives who are "losers," through no fault of their own, or does everyone only react to his/her own situation? And how might "winners" who are paying a little less money for premiums factor that against losing their trusted doctors and their favorite hospitals as part of the bargain?
When Obamacare was just a gleam in its advocates' eyes, there was already a system of health insurance in place that had been cobbled together over the years. It was admittedly imperfect, although it had been tweaked repeatedly to try to improve it. It was set by the states and overseen and regulated by state insurance departments and commissioners. Obama and liberal Democrats, and even some conservatives, have consistently pointed out what they perceive as unfair discrimination and/or inequities on the part of insurance companies under that system, although there were all sorts of laws in many states to help remedy the situation: limits on what restrictions could be placed on covering pre-existing conditions, laws forbidding the cancellation of policies when someone became sick unless fraud had been involved on the part of the patient, the establishment of high-risk pools, the provision of Medicaid for the poor, and prohibiting hospitals from turning away indigent patients.
Did those rules make the system completely fair? Of course not. But the inequities that remained in health insurance were a subset of the more general inequities of life -- such as the reality that some people are wealthier than others, and the wealthier can afford more -- combined with the fact that insurance is a profit-making business. For example, allowing people to sign up with pre-existing conditions without charging them significantly more would tend to reduce profits and could even make that business go out of business rather rapidly. In sum, the unfairness was mostly understandable and not arbitrary, whether people thought it needed remediation or not.
Obamacare was promoted as a program that would not only right those wrongs, but that would create no losers at all. This was always an absurdity, as anyone with a modicum of math knowledge would know. But those were the promises explicitly made by Obama and the Democrats: everyone would save money, no one would lose doctors or hospitals or health plans, the sick and unemployed would be covered, and it would save us all money -- except for the very, very, very rich, whose taxes would be raised.
Well, it hasn't quite turned out that way. The old system had winners and losers, and so does the new one. But they are a very different set of winners and losers. You might say that Obamacare turns the old system on its head, and it's not just the very rich who are penalized, it's the solidly middle class and upper middle class. Not only did those groups not bargain for this, they were explicitly promised it would not happen.
But even without the broken promises, there's another problem with the inequities of Obamacare: they do not flow from anything we recognize as natural consequences, because they are imposed by a government that has made the decision as to who will be the winners and who will be the losers. The dirty little secret of Obamacare (that was never really a secret) is out: it is the most redistributive entitlement program in U.S. history, although it was pitched as something quite different. Edsall quotes Edward Carmines, a political scientist at Indiana University, who writes:
Most of the benefits of the new program will go to the poor and less-well-off and most of the costs will be born[e] by the well off. Neither is true of Medicare or Social Security. When the new law was passed it was hailed by the New York Times as the most redistributive policy in a generation, and they were right. It was not sold as being markedly redistributive, of course, but that is how it was designed and will operate.
Long before Obamacare was passed, the conservative economist and author Thomas Sowell wrote an entire book on the impulse behind redistributive programs, and their consequences. It was entitled The Quest for Cosmic Justice (1999), and in it Sowell contrasted the desire for cosmic justice with traditional justice:
Not only does cosmic justice differ from traditional justice, and conflict with it, more momentously cosmic justice is irreconcilable with personal freedom based on the rule of law. Traditional justice can be mass-produced by impersonal prospective rules governing the interactions of flesh-and-blood human beings, but cosmic justice must be hand-made by holders of power who impose their own decisions on how those flesh-and-blood individuals should be categorized into abstractions and how those abstractions should then be forcibly configured to fit the vision of the power-holders. Merely the power to select beneficiaries is an enormous power, for it is also the power to select victims---and to reduce both to the role of supplicants of those who hold this power.
Obamacare does exactly that: it empowers the government to select beneficiaries and victims according to its own idea of cosmic justice, as though government were an all-seeing, all-knowing judge and jury combined. The result may feel as though there are winners and losers. But when all become supplicants, we are all losers.