The real source of Obamacare’s current problems lies in the law’s complexity. A straightforward way to assure coverage would have been to extend an existing, well-worn program to more people. This is how most other countries guarantee health insurance. In the British National Health Service, there is little that beneficiaries need to do in order to receive health insurance, as all residents are automatically entitled. Other countries rely on private intermediaries that provide insurance — nonprofit insurance funds in Germany or Switzerland, for example, or a mix of proprietary and nonprofit insurers in the Netherlands. Even in those instances, benefits packages and entitlements are highly standardized, making these health-care systems relatively uncomplicated from the standpoint of beneficiaries.
In the United States, political antipathy to government programs precludes this kind of straightforward administrative solution. Faced with such hostility, policymakers regularly rig up complex public-private, and often federal-state, arrangements that are opaque to the public, difficult to administer, and inefficient in their operation — what Andrea Louise Campbell, a professor of political science at the Massachusetts Institute of Technology, and I describe as a Rube Goldberg welfare state — because of the complicated way in which it achieves even basic tasks — and what the political scientist Steven Teles aptly labels a “kludgeocracy.”
The Affordable Care Act’s health-insurance exchanges exemplify the labyrinthine quality of U.S. social policy. The first hurdle for consumers is figuring out if they are eligible for the new benefits: Although anyone lacking insurance can shop for it on the new health-insurance marketplaces, only those with incomes in a certain range are eligible for subsidies. The subsidies vary by income. Those already enrolled in a government health program such as Medicare do not need to buy coverage on the exchanges, a source of confusion for some seniors who assumed they needed to shop for a new plan, perhaps because they (understandably) mixed up the exchanges with the open enrollment period for the marketized versions of Medicare — the Medicare Advantage and the Part D drug plan.