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The Washington elites who designed the law must be bewildered: Why doesn't everyone behave as they do?
View related content: Health Care
People learn from their mistakes. Or they can — and should. Which is the reason we should try to learn from the revelations of mistakes about health care and health insurance since the passage of Obamacare. The evidence is not all in. But it seems that Americans are not behaving as Obamacare’s architects — and many critics — expected.
Start with the assumption that just about everyone wants health insurance. You can easily find polls that support this proposition. Obamacare architects assumed that if you offered health insurance with subsidies for those with relatively modest incomes, those currently uninsured would flock to apply. So far that seems not to have happened. A McKinsey & Co. survey of those thought to be eligible for Obamacare health-care exchanges found that only 11% of those who bought new coverage between November 2013 and January 2014 were previously uninsured.
Two small insurance companies told Wall Street Journal reporters for a Jan. 17 article that only 25% and 35% of those purchasing their policies were previously uninsured. Larger insurers don’t yet have numbers, but it seems that far fewer of the uninsured than expected are signing up. The latest Kaiser Family Foundation poll reported that only 24% of uninsured under 65 had a favorable view of Obamacare while 47% had an unfavorable view.
One reason may be that Obamacare requires policies to cover not just the expenses of catastrophic illness—the sort of thing auto and home insurance policies cover—but routine medical expenses and procedures that many individuals will not need. To that extent Obamacare policies are not insurance but prepayment of routine expenses. Apparently many of the uninsured aren’t interested in prepaying for health insurance any more than they are interested in prepaying their credit cards.
A second assumption of Obamacare’s architects is that health insurance will make people healthier. That assumption has been tested in Oregon. In 2008 the state government, with limited Medicaid funds, held a lottery to determine which people who were eligible for Medicaid would be enrolled. The result was an unusual randomized control trial of similarly motivated people with and without insurance. The results, reported in the May 2013 New England Journal of Medicine, were that after two years there was no significant difference between insured and uninsured in blood-sugar level, blood pressure and cholesterol levels — although those with Medicaid saved money and were less likely to suffer depression.
A third assumption is that those with health insurance are more likely to seek care from physicians and less likely to go to emergency rooms. But the Oregon health study showed that those with Medicaid were 40% more likely to go to emergency rooms than those without insurance.
None of these three assumptions has been conclusively disproved. Obamacare enrollment will go on at least until March 31 and may accelerate. The Oregon health study covered only two years, because Oregon eventually got more Medicaid funding and ended the lottery. Long-term health outcomes for Medicaid enrollees may turn out to be better than for those uncovered.
But the apparent discrepancies between what policymakers expected and how many of the intended beneficiaries of Obamacare seem to be behaving reminds me of the divide described in Charles Murray’s 2012 book “Coming Apart: The State of White America, 1960-2010.” Mr. Murray, my colleague at the American Enterprise Institute, documents the sharp differences in behavior between the upper (in education and income) 20% and the bottom 30% of white Americans.
The upper group has low rates of divorce and single parenthood and high rates of what Harvard political scientist Robert Putnam calls social connectedness. They belong to voluntary associations and churches; they vote and follow public-policy debates. They tend to be connected, engaged and conscientious. The lower (income and education) group has high rates of divorce and single parenthood and low rates of social connectedness. They tend to be disconnected and disengaged, and sometimes heedless. It should not be surprising that they may not respond to the same health-care mandates, incentives and nudges that policymakers and others in the upper group do.
Liberal policymakers have long regarded Scandinavian policies as a model. If a welfare state can work there, they have long argued, it can work here. But the Scandinavian countries have homogeneous populations with high levels of trust, conscientiousness and social connectedness. It is not a coincidence that in the two states with the highest levels of the social connectedness Mr. Putnam described, North Dakota and Minnesota, most people are of Scandinavian or German descent. But policies that work well in Scandinavia or Minnesota and North Dakota won’t necessarily work well in a wider United States, where a much larger proportion of people are socially disconnected.
And such policies may not work as well as they might have in the United States of the 1950s and early 1960s, in which disconnectedness was much less common. That was an America in what I call the Midcentury Moment, a period when World War II and unexpected postwar prosperity produced a conformist and (mostly) culturally homogeneous nation with low rates of divorce and single parenthood, and high rates of social connectedness. A nation accustomed to a universal military draft and wage-and-price controls, and in which increasing numbers worked for giant firms and were members of giant labor unions, probably would have been more amenable to a centralized command-and-control policy like Obamacare than the culturally fragmented America of today.
In the long run of American history, the Midcentury Moment was just that — a moment, an exception, not the rule. We have been in some sense a multicultural nation from our colonial beginnings. The Founding Fathers, seeking to unite Puritan New England, Anglican Virginia, Dutch New York and Quaker Pennsylvania with the Scots-Irish warriors on the Appalachian frontier, determined that the federal government would impose no religious test for office and make no law regarding a religious establishment. They provided for a limited central government and a wide free-trade zone in which local cultures could prevail, local preachers could convert, and local entrepreneurs could innovate.
Obamacare cuts against this grain. The trouble that has resulted — from the architects’ apparent failures to anticipate the behavior of fellow citizens who don’t share their approach to the world, and the architects’ determination to impose their mores, such as contraception coverage, on a multicultural nation — is a lesson to national policymakers, conservative as well as liberal. Govern lightly if you want to govern this culturally diverse nation well.
Mr. Barone is senior political analyst for the Washington Examiner and an American Enterprise Institute resident fellow. His latest book is “Shaping Our Nation: How Surges of Migration Transformed America and Its Politics” (Crown Forum, 2013)
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