Bob Schwartz

You may not want to think or talk about the Affordable Care Act. Who can blame you? Politicos and talking heads are doing enough for all of us.

And yet, October 1 marks the start of people reading the menu of health insurance options and deciding which way to go. Which is why the volume of debate is once again up to 11 and why it is harder than ever, even after all this time, to make sense of any of it.

Previous posts have covered the process: how ACA is based on a Republican proposal, how Republicans ran screaming away from their own proposal, how the Supreme Court narrowly allowed it to proceed, etc. Now is the time to consider the substance and the merits, reluctantly. Reluctant because some kind of truly broad and truly affordable health coverage really is necessary for a civilized, modern and (in some segments) wealthy society, so a critique should not appear to deny that. Reluctant because, under the circumstances, ACA may really be the best we can do, even if that is not saying much.

But here are a few truths.

1. This is the most complicated, Rube Goldberg-like social program in American history. Comparisons to Social Security and Medicare—as in “people were skeptical or opposed to Social Security and now these programs are an integral part of American life”—are inapposite. Think: one concept, one law. That may be oversimplifying, but not much. Social Security was and is a way to create a fund to help older and disabled Americans who can’t help themselves. The way it’s evolved may be complicated and not to all tastes, but the basic concept remains. The same can be said about Medicare.

The single concept of ACA is more elusive, despite the name making clear it is about affordability. Separate from the execution and success in that regard, ACA is also about the reach and availability of coverage. More properly, it might be called the Market-Based Universally Available Affordable Care Act, a name that would hint at its complexity.

2. It may be too complicated to manage. To get to the truth of this, we have to look bigger. Bigger, as in the manageability or not of the American government. The loud complaint from some corners is that the government is “too big.” This is a misplaced critique. The problem is that very big enterprises are very hard to manage effectively. Just shrinking an unoptimally managed enterprise lessens the damage and the cost, but it doesn’t change the fact of ill management. Scientific management tells us that in theory any enterprise of any size can be managed, by discovering or devising the appropriate principles and executing soundly. But there is a cousin to “too big to fail” that is “too big to run.” Maybe the government is that.

Maybe the ACA is that also, too big and too complicated. Which touches back to the idea of its not having one single concept. It seems clear, as it did to the ACA proponents, that so-called universal, single-payer health care would never be accepted in “free market” America. If that wasn’t always clear, the debacle of the Clintoncare proposal, engineered by Hillary during the Clinton administration, put it out of reach for a generation. The only way to get anything, rather than nothing, was to patch together components that were variously consistent with popular ideas, market mechanisms, federalism, healthy business and industry interests, along with political and legal constraints. The wonder isn’t that a combination car/boat/plane gets designed and built. The wonder is that it can drive or float or fly.

3. The American political environment is distrustful, skeptical and toxic. Social Security was born during the worst economic crisis ever. So the building of an historic safety net was fitting. But on top of that, even with virulent opposition, there was a widespread understanding that we were all Americans, and part of that was caring for others, and part of that care was trusting that the government would, within the limits of human fallibility and self-interest, do the right thing.

We can pray for the return of that context, but it isn’t today. Today we have an unprecedented spectacle of a small but powerful segment of the country working desperately, and maybe effectively, to make sure that ACA is repealed or at least fails miserably. The reasons are as complex as the act itself, a bit about the shortcomings of the law, but, not surprisingly, mostly about politics. Proponents find themselves in the position of defending the act, promising to improve it, and trying to make it work—all the while perhaps harboring doubts in the places they can’t talk about that it won’t, not entirely.

Let’s hope it does work, a little. Because American health care is so broken, and for the moment, this is what we’ve got.