The ACA had its most effective cost-control mechanisms stripped by its political opponents. Sen. Lieberman (a turncoat Dem who had campaigned for John McCain) forced the removal of the public option, which would have helped hold prices down through competition. The Supreme Court struck the requirement for states to participate in Medicaid expansion, which limited the benefits for millions in a swath of conservative states. And Republicans in Congress removed the individual mandate, which enabled healthy people to go without coverage, raising prices for everyone else.

It's also important to keep in mind that reforming the US healthcare + insurance system was always going to be an evolutionary, multi-stage process, because of its complexity.

You shouldn't change all the parts in an engine to different specifications at the same time.

The ACA therefore blended structural improvements (insurer admin cost caps, standardized benefits, no prior condition exclusions, guaranteed access, etc.) with lubrication (individual mandate) in an effort to move the whole morass forward.

The worst part about the ACA is that neither party tried to pass ACA Pt 2, that went further. (And yes! That could have been a Republican effort too!)

The previous system was broken. The current system is less broken. It's possible to create an even less broken future system.

The real ridiculousness is anyone campaigning on status quo and/or 'it's impossible to improve things.'

In a constitutional republic like the US, it’s simply too risky to execute major improvements in a big bang fashion. It’s not that different from engaging in a multi-decade software migration project. Sometimes, small changes is really the only path forward.

Part of the reason why Obama, initially a unifying force, eventually became known as a Divider In Chief (in addition to some racial commentary around police work) was that the bold changes of Obamacare left too many victims behind who ended up worse off.

You have to start with the principles of the country and work with them in mind, if you expect to be successful. You also have to assume future change will be dependent on the political winds of the future.

There is likely a lesson somewhere here about introducing “lean healthcare” style of changes instead of “big bang,” but I haven’t taken the time to articulate them.

Maybe starting with principles and making yearly changes that can easily be undone or redone by future administrations is the only path forward.

> Maybe starting with principles and making yearly changes that can easily be undone or redone by future administrations is the only path forward.

I'd trend in the opposite direction. The death of bipartisanship (due to changes in media, education, and gerrymandering: none likely to change soon) render democracies incapable of solving large problems over a multi-voting cycle timespan effectively.

Ergo, the best solution is to punt to an independent body, in the same way central bank management was done.

It makes more sense to have democratically-elected government responsible for and deciding the details, but not the strategic arcs.

Healthcare, national debt / budget deficits, military procurement, voting rights enforcement, education policy would all be better off in consistent hands, even if occasionally less capable ones.

Sometimes, it's more important to keep to an approach than have the optimal approach.

Now? Most democracies get the worst of both worlds there.

The problem, at least in our American mindset, is that since America’s birth, there has been a marked reluctance to have unelected bodies be responsible for anything that impacts the people, ESPECIALLY anything that presumes some globalization intention or some overarching aristocratic ruler (and with good reasons).

Central banking works because problems are instantly catastrophic to the system, whereas healthcare systems are not that fragile. They can survive broken for a long time.

Everybody is okay having a central lender of last resort because the problem is technical, typically unemotional, and in general, benefits every participant equally (because everybody loses is the system collapses).

Healthcare is different in that it affects MY decisions on a regular basis. America is individualistic and self reliant. We never want some government bureaucrat deciding what treatment [I] should or shouldn’t get if [I] can afford it with my own independently earned money. [You] should take care of [Yourself], save your own money, eat healthy, exercise, or not, and live with your consequences.

States have power too. So it does not matter much if some Bernie politician has some fantasy about some central single payer system that has some theoretical average benefit if it restricts ME from making my own choices.

Other countries have other cultures and foundational principles, so Bernie may have better luck there.

But not here.

Is it limiting? Probably for this case. But the fact is the system works for many other things. Everyone wants to come here. It’s the best country in the world etc etc. It does not have to be perfect. But it’s the best we get with the philosophy that made the country what it is.

Does it suck for healthcare? Overall, probably. But not for [ME].

We saw the system has limitations in other cases (think pandemics etc, but even now, many Americans can’t forgive the politicians that kept them imprisoned in their own homes).

You have a right to life, liberty, and pursuit of happiness. But not to anything that must be provided by someone else, like healthcare.

The Supreme Court is not “a political opponent.” It’s literally the way the country works. It found the requirements for states to participate to be unconstitutional. In fact, it was also SCOTUS who eventually determined in 2012 that the individual mandate penalty was functioning as a tax for constitutional purposes. This was the basis for upholding the law. The mandate itself was not upheld under the Commerce Clause but survived because the financial penalty was deemed a tax.

> The ACA had its most effective cost-control mechanisms stripped by its political opponents.

Because of lobbyism, healthcare sector is extremely strong politically and don't want to reduce their income, Democrats aren't immune to that they have mostly been just as pro corporate as the republicans are they just are pro different corporates.