Why Did Obama Deviate from His Primary Campaign’s David Cutler Hundred-Flowers No-Mandates Health Care Reform Plan, Anyway?

Over at the New Republic, I see that the extremely thoughtful Henry Aaron and Harold Pollack are irate in their: “Single-Payer Healthcare Supporters Complain About Obamacare Problems”:

It has been a rough two months for the Affordable Care Act and its defenders…. anger over the botched rollout is understandable, but these recriminations are poorly timed—and just plain wrong…. The ACA is working reasonably well in some places–California, Connecticut, Kentucky, Washington, and the District of Columbia…. These under-reported success stories show that insurance exchanges can work, if properly administered…. The human benefits are real, from California to Breathitt County in rural Kentucky. These successes make the federal government’s dismal rollout even more embarrassing…. Given that complexity, some on the left say, life would be simpler if only Congress had been willing–which it was not–to scrap all current arrangements and replace them with a single, federally administered health insurance plan. Those on the right regard this complexity and say that life would be simpler if only Congress had been willing—which it was not—to scrap all current arrangements and replace them with income-related vouchers people could use to help pay for private insurance of their choice…. These polar-opposite camps each disdain the kludgy fixes of incremental politics. And yet, incrementalism is what most Americans want….

We understand [Robert] Kuttner’s frustration. We do not share his disdain for the ACA or for Obama…. Obama bet his historic legacy on a reform that, however imperfect, brings health insurance to millions, improves its quality, and helps slow spending growth. The real beef of those who seek a more radical rewiring of our healthcare system is not with the president. It is with the coalition of labor, healthcare, disability, and anti-poverty groups that coalesced during 2007 and 2008 around a health reform model that later became the ACA. Candidates Hillary Clinton, Obama, and John Edwards endorsed similar health plans…

The time to debate the historical accomplishments of the Obama presidency is, I think, not yet here. But I would note that the presidency has six more-or-less equal parts–(i) inspiring America through rhetoric, (ii) maintaining and strengthening his coalition, (iii) choosing technocratic policies, (iv) skillful legislative tactics, (v) filling the federal government with people who want to implement them, and (vi) implementing them. And I would note that I have not yet heard convincing arguments that as of this moment it looks as though Obama has not been anything other than a failure on (v) and (vi), that it would be difficult to say that Obama understood either the macroeconomic situation or the legislative role of Reconciliation and the filibuster and so has been a deep disappointment on (iii) and (iv), and that as a result he has significantly underperformed on (ii) as well.

But I do think that it is important to note that the ACA is not Obama’s primary-time health-care proposal.

Obama’s primary-time health-care proposal was David Cutler’s. And David was, to say the least, extremely skeptical about the usefulness of employer or individual mandates. Make coverage affordable, the line was, through many different avenues. See how many people sign up. And hold mandates in reserve in the case that the reformed system still has too much free-riding in it. Thus, at least as I envisioned it when I was arguing for Obama in the 2008 Democratic primaries, near-universal coverage would be attained via some combination of:

• Lowering the Medicare eligibility age;
• Expanding Medicaid eligibility;
• Giving individuals and small business the opportunity to join an actuarial pool–either through an already-running or newly set-up state-run exchange like Massachusetts, or through piggy-backing on the already-functioning and already-effective Federal Employees’ Health Benefits Program;
• Providing a Medicare- or Medicaid-like “public option” for those ineligible for the already-functioning programs; and
• Expanding the nation’s network of free clinics and government-supported preventive services.

And, at least as I envisioned it in early 2008, the legislative coalition to pass this would have been assembled by:

• Threatening to do Medicare-for-all single-payer via Reconciliation in August 2009 if no bill had been passed by then.

That line of approach seems to me to be immune from all the criticisms that Pollack and Aaron make of alternative legislative and implementation strategies. I still do not understand why it wasn’t adopted. And I would like to know…