More than 21/2 years have gone by since the Affordable Care Act, aka Obamacare, went fully into effect. Most of the news about health reform since then has been good, defying the dire predictions of right-wing doomsayers. But last week brought some genuine bad news: The giant insurer Aetna announced that it would be pulling out of many of the exchanges, the special insurance markets the law established.
This doesn't mean that the reform is about to collapse. But some real problems are cropping up. They're problems that would be relatively easy to fix in a normal political system, one in which parties can compromise to make government work. But they won't get resolved if we elect a clueless president (although he'd turn to terrific people, the best people, for advice, believe me. Not.). And they'll be difficult to resolve even with a knowledgeable, competent president if she faces scorched-earth opposition from a hostile Congress.
The story so far: Since Obamacare took full effect in January 2014, two things have happened. First, the percentage of Americans who are uninsured has dropped sharply. Second, the growth of health costs has slowed sharply, so that the law is costing both consumers and taxpayers less than expected.
Meanwhile, the bad things that were supposed to happen didn't. Health reform didn't cause the budget deficit to soar; it didn't kill private-sector jobs, which have actually grown more rapidly since Obamacare went into effect than at any time since the 1990s. Evidence also is growing that the law has meant a significant improvement in both health and financial security for millions, probably tens of millions, of Americans.
So what's the problem?
Well, Obamacare is a system that relies on private insurance companies to provide much of its expanded coverage (not all, because expanded Medicaid is also a big part of the system). And many of these private insurers are now finding themselves losing money because previously uninsured Americans who are signing up turn out to have been sicker and more in need of costly care than we realized.
Some insurers are responding by hiking premiums, which were initially set well below what the law's framers expected. And some insurers are simply pulling out of the system.
In Aetna's case, there's reason to believe that there was also another factor: vindictiveness on the part of the insurer after antitrust authorities turned down a proposed merger. That's an important story, but not central to the broader issue of health reform.
So how bad is the problem?
Much of the new system is doing pretty well--not just the Medicaid expansion, but also private insurer-based exchanges in big states that are trying to make the law work, California in particular. The bad news mainly hits states that have small populations and/or have governments hostile to reform, where the exit of insurers may leave markets without adequate competition. That's not the whole country, but it would be a significant setback.
But it would be quite easy to fix the system. It seems clear that subsidies for purchasing insurance and in some cases for insurers themselves should be somewhat bigger--an affordable proposition given that the program so far has come in under budget and easily justified now that we know just how badly many of our fellow citizens needed coverage. There should also be a reinforced effort to ensure that healthy Americans buy insurance, as the law requires, rather than them waiting until they get sick. Such measures would go a long way toward getting things back on track.
Beyond all that, what about the public option?
The idea of allowing the government to offer a health plan directly to families was blocked in 2010 because private insurers didn't want to face the competition. But if those insurers aren't actually interested in providing insurance, why not let the government step in (as Hillary Clinton is in fact proposing)?
The trouble is Congress: If Republicans control one or both houses, it's all too likely that they'll do what they do best--try to sabotage a Democratic president through lack of cooperation. Unless it's such a wave election that Democrats take the House, or at least can claim an overwhelming mandate, the obvious fixes for health reform will be off the table.
That said, there may still be room for action at the executive level. And I'm hearing suggestions that states may be able to offer their own public options; if these prove successful, they might gradually become the norm.
However this plays out, it's important to realize that as far as anyone can tell, there's nothing wrong with Obamacare that couldn't be fairly easily fixed with a bit of bipartisan cooperation. The only thing that makes this hard is the blocking power of politicians who want reform to fail.
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Paul Krugman, who won the 2008 Nobel Prize in economics, writes for the New York Times.
Editorial on 08/20/2016