In the Democratic imagination, Obamacare is historic because it finally gives the United States a “universal” system of health-insurance enrollment. Ever since Harry Truman pushed for national health insurance in the 1940s, it has been the dream of liberal politicians with presidential ambitions to become the leader who finally brought the United States out of the wilderness of nations whose health systems are supposedly uncivilized. Whoever led the way to a national health-insurance plan would join the other architects of the modern welfare state — FDR and LBJ — in the liberal pantheon of heroes.
That was certainly a primary motivation for Barack Obama. During the 2008 presidential campaign, he opposed the individual mandate — the centerpiece of the “universal coverage” scheme that was eventually enacted in Obamacare — on the grounds that it would be too much of a burden for many low-wage households. This position allowed him to differentiate himself from his main rival for the nomination, Hillary Clinton. During the bruising primary campaign, Obama was not at all shy about using this policy difference to suggest, in ads and debates, that Clinton, a longtime staunch advocate of the individual mandate, was insensitive to the practical economic realities of the uninsured.
But once in office, the newly elected president had a swift “change of heart.” By late spring 2009 he not only had dropped his objections to the mandate but had become its fiercest defender, declaring it essential to the kind of health plan he wanted Congress to pass.
What happened? Ron Suskind’s book on the first two years of the Obama presidency details the transformation. In early 2009, the White House staff prepared a memo for the president that suggested that a reform plan without the mandate would reduce the ranks of the uninsured only to 28 million people (from a projected 50 million). A plan with the mandate would reduce the number of uninsured residents in the United States far more, to under 10 million.
So a health plan with the individual mandate could more plausibly be described as “universal coverage” than could a health plan without it.
It’s clear now that, notwithstanding the position he took during the campaign, Obama was always aiming for the history books. If nothing else, he has always been a man of great ambition. And once elected, he felt free to abandon his previous position on the mandate to pursue his goal of becoming the liberal leader who delivered the next great entitlement benefit. Of course, that Democrats held once-in-a-generation supermajorities in the House and Senate only further encouraged him to “go big” in early 2009.
This history of Obamacare’s political origins makes it all the more ironic that Obamacare, from what we now know, should not be considered a “universal coverage” plan, even by the benchmark the administration was using in 2009.
Estimates from the Congressional Budget Office (CBO) point to this conclusion. In its latest assessment of the law, released in conjunction with new budget projections, the CBO indicates that the number of uninsured residents in the United States will never fall below 31 million — three million more uninsured people than was estimated for the non-mandate plan President Obama rejected — and that the insured will never be as much as 90 percent of the population.
And even that estimate is highly optimistic. It assumes that 70 percent of the population eligible for the Medicaid expansion will eventually enroll in the program. As of today, however, only 24 states have governors and legislatures that would likely agree to move ahead with expansion, and that number could easily fall as more state policymakers come to the realization that Medicaid is far too often failing its current enrollees. It makes little sense in that context to dramatically expand a program that credible independent observers believe needs significant reform.
Further, the individual mandate itself isn’t likely to work as the CBO assumes it will. For starters, the taxes imposed on those going uninsured are far below the premiums most households will be required to pay for “qualified” insurance. For instance, in 2014, a family of four with $50,000 in total income will have to pay an uninsured tax of $500. But their premiums in the Obamacare exchange, even with a large federal subsidy, are likely to come in around $3,000.
Obamacare advocates argue that the tax on the uninsured need not be onerous to compel enrollment in health insurance. The mere existence of the tax is supposed to create an “aura of obligation” that magically convinces millions of Americans to sign up with expensive insurance coverage that is not in their self-interest. In other words, the mandate was supposed to create the perception that not buying health insurance was somehow “unlawful.” The CBO bought into this way of looking at the legislation and assumed that eventually large numbers of Americans would sign up for health insurance even though they could reduce their costs substantially by paying the tax instead and waiting to get health insurance until they need it.
The CBO’s approach to estimating the effects of the mandate was always suspect, but it is even more so in the wake of the Supreme Court’s decision on Obamacare last year. The majority opinion of the Court makes it clear that Congress had no authority under the Constitution to create an obligation to purchase health insurance. All Congress could do was to create a legitimate choice between two perfectly legal options: either sign up for government-sanctioned health insurance or pay a tax. Both are equally legitimate — at least in the eyes of Chief Justice John Roberts. If this becomes the prevailing understanding of the mandate, then many millions of relatively healthy people will quite naturally pay the tax rather than sign up for coverage. The result will be far more uninsured in the future than the CBO currently estimates.
So despite all of the self-congratulatory rhetoric from the law’s advocates, there’s little prospect that Obamacare will actually deliver on “universal coverage.” Instead, it should be viewed for what it will likely become: a very expensive new health-entitlement program that the government will try to control like the other programs already on the books — with regulated prices. In the end, that approach will lead to the same problems with quality that plague Medicaid.
It doesn’t have to be this way. It is possible to construct a real universal insurance plan — with everyone in the country protected from the kind of high-cost medical event that insurance is intended for — without the onerous mandates, taxes, and regulations of Obamacare. What’s necessary is a truly functioning marketplace, with consumers, not the government, driving the allocation of resources. As more and more Americans see up close the failures and shortcomings of Obamacare, there will be renewed interest in pursuing such a commonsense plan.
— James C. Capretta is a senior fellow at the Ethics and Public Policy Center and a visiting fellow at the American Enterprise Institute.