None of this means that government cannot be reformed. Rauch’s book does not counsel despair. Rather, it counsels modesty, simplicity and incrementalism in legislative efforts. You can make big changes to small programs, and small changes to big ones. But comprehensive solutions tend to produce comprehensive resistance. And the more sweeping the stakes, the greater the chance of political disaster — whether your name is Clinton or Gingrich, Bush or Obama — when your bill goes down to defeat.
The lesson for Democrats should be obvious. They wanted, admirably, to help the low-income uninsured, and Americans with pre-existing conditions. And that’s exactly what they should have done — with tax credits or vouchers or a Medicaid expansion for the poor, and better-funded risk pools for the sick.
Such a bill would have had many fewer beneficiaries — but far fewer enemies as well. It wouldn’t have transformed the system, controlled costs for the long term, or guaranteed universal care. But permanent solutions are probably beyond what any single piece of legislation can accomplish.
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