The Affordable Care Act, President Barack Obama's signature accomplishment, marks the most significant expansion of the social safety since the establishment of Medicare in the 1960s. Although the health reform has effectively lowered the uninsured rate to record lows, the machinery of the ACA has been battered by numerous glitches, according to Paul Krugman, PhD, a professor of economics and op-ed columnist for The New York Times.
"Obamacare is […] what engineers would call a kludge: a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks," Dr. Krugman, professor in the Graduate Center Economics PhD program and distinguished scholar at the Luxembourg Income Study Center at the City University of New York, wrote in a recent column in NYT.
The ACA has been hotly contested since its inception. Cooperation on the matter across the partisan divide is a rare occurrence, with virtually all Republicans in Congress pining for its repeal. Dr. Krugman says now the question for progressives is determining if the ACA's shortcomings mean Democrats should "litigate their own biggest political success in almost half a century, and try for something better."
He says Democrats should not renege on the ACA and instead seek incremental change to the law. If we were to start over from scratch, many health economists would likely recommend a single-payer, Medicare-for-all type of system, according to Dr. Krugman. However, in 2010, a "single-payer wasn't a politically feasible goal in America" for three main reasons.
The first reason is because private insurers wage substantial power, according to Dr. Krugman. "Private insurers played a major part in killing health reform in the early 1990s, so this time around reformers went for a system that preserved their role and gave them plenty of new business," he wrote.
Second, significant additional tax revenue would be required to pay for a single-payer system, which would pose a great burden on the middle class. While higher taxes would be offset by the reduction or elimination of insurance premiums, "it would be difficult to make that case to the broad public, especially given the chorus of misinformation you know would dominate the airwaves."
Finally, switching to a single-payer system would disrupt coverage for tens of millions of families who are currently satisfied with their employer-sponsored health plans.
"Even if you imagine a political earthquake that eliminated the power of the insurance industry and objections to higher taxes, you'd still have to protect the interests of workers with better-than-average coverage, so that in practice single-payer, American style, would be almost as kludgy as Obamacare," wrote Dr. Krugman.
The ACA was designed to skirt these obstacles. It does so by preserving the role of private insurers, by combining regulation and subsidies to provide coverage for the poor, rather than merely an expansion of government programs. It also leaves employer-sponsored health plans intact, according to Dr. Krugman.