Obamacare: The National Road to Where?

In the middle of the 18th century, George Washington was a colonel with the British army, assigned to do something about the competition between the French and the British colonists for the trade with Native Americans.  The exchange of manufactured goods desired by the Indians and the fur pelts they could provide in trade was a very profitable business.  The British could usually offer better trading deals, but the French had been cultivating the friendship of the Indians much longer.  Each saw the other as infringing on its territory, and the Battle of Fort Necessity, in the Laurel Highlands of southwestern Pennsylvania, launched the French & Indian War, a microcosm of the global conflict between the French and British imperial powers, known in Europe as the Seven Years War (1756-1763).

Washington's early experience in the region led him to believe that a good road from the East through the Allegheny Mountains was essential to development of Western lands and expansion of what was to become a new nation.  His vision later became the National Road from Cumberland, Maryland to Wheeling, Virginia.  (That part became West Virginia during the Civil War, and the National Road later carried travelers much farther west.)  Very substantial funding was approved when Thomas Jefferson was president.  Jefferson worried that the project would become a great sinkhole into which money would disappear, imagining that every member of Congress would be trying to secure contracts for friends.  It is unclear whether Jefferson was the first to worry about profligate federal spending on a "pork barrel" project, but what he wrote at the time was to be mirrored in many criticisms of public spending over the next two centuries.

Alexander Hamilton had a vision of a powerful central government that would collect taxes and spend money, helping to expand the United States with federal subsidies for "internal improvements" such as roads and canals and a strong central bank to foster commerce.  This was developed further, in the second quarter of the 19th century, into Henry Clay's "American System."

All along the way, there have been powerful dissenting voices.  Just as Hamilton and Jefferson had opposing views on the merits of a strong central government, there have, ever since, been dramatic differences in political philosophy between those who believe in using the power of the federal government to tax and spend to "provide for the general welfare" (the phrase used in the Constitution's description of the powers of Congress) and those who believe most of these important functions should be carried out by the states or left in private hands.

Hamilton and Jefferson never imagined public financing of the nation's system of health care, likely at least in part because two centuries ago health care had relatively little to offer.  Louis Pasteur, who deserves much credit for development of the germ theory of disease, wasn't born until 1822, and antibiotics would have to wait another century to begin to cure our ills.  In the run-up to the enactment of Obamacare, some students of history pointed to a 1798 law providing for public funding of hospitals to care for sick and disabled sailors, paid for through a tax on private marine merchants.

Whether one can - or should - extrapolate from a system of health care for veterans to a national health service (like the one in Britain) that takes care of everyone is very much an open question.  For each veteran of our armed services who praises the VA health care system and relies upon it exclusively, it is easy to find another who is glad to have access to the private system and sees it as vastly superior in quality.

Obamacare does not create a National Health Service.

But there are many among both its proponents and its enemies who see it as the first steps down that National Road.



Some, including your faithful essayist, see it as a move - welcome, but insufficient - toward universal coverage.  As you know if you are a regular reader, I regard our status as the only nation in the industrialized West to fail to provide universal coverage for, and universal access to, health care to be a national disgrace.

The new law requires everyone to have health insurance.  This is to be accomplished through a hodgepodge of mechanisms, from mandated purchasing (with subsidies for the needy) through health insurance exchanges to expansion of the publicly funded Medicaid system for the more severely needy.  But the enforcement mechanism for the mandate is weak, the subsidies are likely to prove inadequate, and the states have been told by the Supreme Court that Congress cannot make them expand Medicaid. So patients, doctors, and hospitals are waiting, none too optimistically, to see how this all plays out.

I may be among the least optimistic.  I believe the number of uninsured, now standing at about 50 million, will drop by no more than half in the next decade unless we do much more to change the way health care is financed in this country.

The question remains how we should go about it. Should we have a mix of public and private mechanisms for financing purchase of health care services, such as we have now?  If so, how will we cover everyone, when so many will continue to find private insurance unaffordable?  If we address that problem by subsidizing the purchase of private insurance very generously, how can we avoid enriching the health insurance industry (and its "fat cat" CEOs and stockholders)?  To carry that a step further, is it even possible to expand health insurance to cover everyone without either enriching or eliminating the private health insurance industry?  Either we subsidize the purchase of private health insurance so generously that everyone can afford it (and it becomes even more profitable than it is now), or we fail to do so, in which case we must expand public financing so greatly that everyone who can move into the less-costly public system will do so, and the private health insurance industry will serve only the most affluent.

I do not claim to have the answers to these questions.  I have opinions about what would work, what would be efficient, and what it would take to ensure high quality. But there are powerful interests opposing change, and vast swaths of the general public stand opposed to change, because they are satisfied with what they have in the current system.  If you are not suffering, it is more difficult to see how things could be so much better.

Remember Washington, looking at the precursor to the National Road.  Soldiers, though they might curse it, could march along that road.  Horses could negotiate it, if not without many a stumble and an occasional fall. Wagons could make it through in good weather, though they were likely to get mired down if it had rained recently.  Washington thought it should be wide and smooth.  Think about your road to readily accessible, high-quality health care.  Have you gotten mired down in that muck? Should we not build a road that is wide and smooth?

We should.  And we must.