It is for an
odd reason buried beneath two and a half years of Republican political
condemnations: the architecture of the Affordable Care Act is based on
conservative, not liberal, ideas about individual responsibility and the
power of market forces.
This fundamental ideological paradox, drowned out by partisan shouting
since before the plan’s passage in 2010,
explains why Obamacare has only
lukewarm support from many liberals, who wanted a real, not imagined,
“government takeover of health care.” It explains why Republicans have
been unable since its passage to come up with anything better. And it
explains why the law is nearly identical in design to the
legislation Mr. Romney passed in Massachusetts while governor.
The core drivers of the health care act are market principles formulated
by conservative economists, designed to correct structural flaws in our
health insurance system — principles originally
embraced by Republicans as a market alternative to the
Clinton plan
in the early 1990s. The president’s program extends the
current health
care system — mostly employer-based coverage, administered by commercial
health insurers, with care delivered by fee-for-service doctors and
hospitals — by removing the biggest obstacles to that system’s
functioning like a competitive marketplace.
Chief among these obstacles are market limitations imposed by the
problematic nature of health insurance, which requires that younger,
healthier people subsidize older, sicker ones. Because such
participation is often expensive and always voluntary, millions have
simply opted out, a risky bet emboldened by the 24/7 presence of the
heavily subsidized emergency room down the street. The health care law
forcibly repatriates these gamblers, along with those who cannot afford
to participate in a market that ultimately cross-subsidizes their
medical misfortunes anyway, when they get sick and show up in that E.R.
And it outlaws discrimination against those who want to participate but
cannot because of their medical histories.
Put aside the considerable
legislative detritus of the act, and its aim is clear: to rationalize a
dysfunctional health insurance marketplace.
This explains why the health insurance industry has been quietly
supporting the plan all along. It levels the playing field and expands
the potential market by tens of millions of new customers.
The rationalization and extension of the current market is financed by
the other linchpin of the law: the mandate that we all carry health
insurance, an
idea
forged not by liberal social engineers at the Brookings Institution but
by conservative economists at the Heritage Foundation. The individual
mandate recognizes that millions of Americans who could buy health
insurance choose not to, because it requires trading away today’s wants
for tomorrow’s needs. The mandate is about personal responsibility — a
hallmark of conservative thought.
In the partisan war sparked by the 2008 election, Republicans
conveniently forgot that this was something many of them had supported
for years. The only thing wrong with the mandate? Mr. Obama also thought
it was a good idea.
The same goes for health insurance exchanges, another idea formulated by conservatives and supported by
Republican governors and
legislators
across the country for years. An exchange is as pro-market a mechanism
as they come: free up buyers and sellers, standardize the products, add
pricing transparency, and watch what happens. Market Economics 101.
In the shouting match over the health care law, most have somehow missed
another of its obvious virtues: it enshrines accountability — yes,
another conservative idea. Under today’s system, most health insurers
(and providers) are accountable to the wrong people, often for the wrong
reasons, with the needs of patients coming last. With the transparency,
mobility and choice of the exchanges, businesses and individuals can
decide for themselves which insurers (and, embedded in their networks,
which providers) deserve their dollars. They can see, thanks to the
often derided benefits standardization of the reform act, what they are
actually buying.
They can shop around.
And businesses are free to decide
that they are better off opting out, paying into funds that subsidize
individuals’ coverage and letting their employees do their own shopping,
with what is, in essence, their own compensation, relocated to the
exchanges.
J.D. Kleinke is a
resident fellow at the American Enterprise Institute, a former health care executive and the author of the novel “Catching Babies.”
Bernie Sanders
