From Megan McArdle at Bloomberg, Republicans Should Kill Obamacare or Let it Die:
Some forms of government policy are built of political concrete. Once done, they cannot be renovated, added to or even destroyed without immense cost; for that reason, they tend to go on much as they always have, for good or for ill.
This was the problem that Democrats faced with Obamacare. Other countries, it was often observed, had a national guarantee of health insurance; surely, we could build a system very much like those. But the other countries had built their systems earlier, when there weren’t so many concrete towers already in the way. By the time Obamacare came on the scene, America already had government programs that were propping up health care for almost everyone in the country: tax-subsidized employer-sponsored health insurance, Medicare, Medicaid, the VA. No one was willing to shoulder the cost of knocking those things down and designing a rational, well-built structure to take their place, so instead the administration threw up an annex next to the Medicaid edifice, and tore down the little remaining patch of ground that wasn’t government-subsidized, and threw up a new tower to hold its residents.The planning was haphazard, the work shoddily done, and the result kept threatening to collapse.
And yet it was locked in. That whole “political concrete” thing. For the enthusiasts, the very difficulty of alteration was not a bug but a feature, because it meant that it would be hard for Republicans to undo. So we were all left with a subpar system that is difficult to either repair or replace.
You do not fix a concrete eyesore in stages. You either knock it down, or you leave it where it is and learn to live with its flaws. If Republicans want to actually do a radical renovation of our nation’s health policy architecture, then they should get a reasonable estimate of the costs, grit their teeth, and go ahead and actually build something sound, and enduring, while demolishing substantial portions of the ugly and unsustainable mess we currently have.
I also contend that viewing it as a broad systemic problem may be misleading. A few underwriting rules would solve the uninsured questions. The poor could actually have coverage purchased for them so they will not be able to game the pool.
But this requires that the tough decisions must be made, not delegated and hidden in a rat hole of mandates and indirect subsidies. What will and will not be covered.
The first rule of politics is to ignore the first rule of economics.