We already have a health care system that resembles a kind of centrist soup. With Obamacare, the exact proportions may be different, but the soup’s ingredients remain exactly the same.


‘Obamacare’, aka the Affordable Care Act, is now under implementation. It passed all three branches of the federal government including a Supreme Court challenge, it survived a big national election including the re-election of the president who enacted it, it has endured through 42 attempts by House Republicans to repeal or defund it and a government shutdown aimed at derailing it. It’s here to stay.

And what is it? Essentially, it’s an attempt to use government power to control the costs of health care and insure more people. It’s done by requiring Americans to buy health insurance, and in exchange includes many regulations about what kind of things insurance companies must cover.

We libertarians don’t typically agree with things like that. We usually oppose using government force to do anything that isn’t necessary for the protection of individual rights. So why, as many people have been asking me, am I saying positive things about Obamacare on the radio and, much to the chagrin of my fellow libertarians, repeating over and over that I’m ‘open-minded’ about the legislation working?

Well it’s largely because I’m distinguishing between what I believe ideologically (what I want in principle) and my observations of America in reality (what I see in practice).

In practice, while the quality of American health care – when people get it – is very good, it’s not at all good at access or cost-effectiveness. Our health care system is ranked by the World Health Organization at 38th in the world, despite having the highest, most insanely out-of-control costs in the world. (That’s right: we’re number 1 in cost and number 38 in what we get for it.)

It’s also extremely inequitable, with the greatest burden to pay the highest costs landing upon the middle class. It emphasizes expensive treatments while ignoring preventive care. Even when people have health insurance, it’s crap: insurance plans have been covering less and less for more and more, and the potential of huge out of pocket health care costs has simply become a fact of life in the United States. The government is the biggest insurer in the system, with Medicaid for the poorest Americans and Medicare for retirees, and lots of programs at the state level aimed at covering the people falling through various cracks in the system’s shell.

The recipe for the American health care soup contains a whole list of ingredients: public funds and private funds, regulations, insurance plans, programs, motivations, tax codes, interests, profits, risk pools.*

What changes under Obamacare? Well, private-sector insurance companies are still in charge of covering people, but now they have even more customers. In exchange for these extra customers, the government mandates that they must cover pre-existing conditions and provide preventive care. There are numerous cost control measures in the legislation too, like mandating that insurers spend at least 80 percent of their revenues on their customers’ care and encouraging competition with the so-called online ‘marketplaces’ that have been making so much news lately.

So, in this recipe, Obamacare has the effect of changing the mixture – the exact proportions – but not fundamentally altering the nature of the meal or even the list of ingredients! If we want to make the new American health care system at home from scratch, we still have to include public funds and private funds, regulations, insurance plans, programs, motivations, tax codes, interests, profits, risk pools.

The Affordable Care Act may even…. get this!… make the soup slightly more palatable to taste. Acceptance of pre-existing conditions, for example, means people like my wife could now get health insurance coverage for the first time in years. Some of the cost controls might actually work. I hope they do.


Now, if I had my choice as a libertarian, I wouldn’t order the Affordable Care Act to begin with. But I also wouldn’t order Medicare, Medicaid, Social Security or any other big government programs! Right?

Libertarians often discuss our ideals about how things should be. But how to get there, what path should be taken, and what is best in the meantime remain a matter of controversy. If a 14-ingredient government program existed, and no matter how hard we fought we didn’t have the votes to bring it all down, is it always better to take it down in the pieces we can, even if only 2 or 3 of the ingredients, and even if the country will be – practically-speaking – worse off for its dysfunction in the meantime?†

The truth is, my preferred option – a completely competitive, free marketplace for insurance, private charity-funded insurance for those who can’t afford it and a minimal government safety net – just isn’t on the menu right now.

If my option isn’t on the menu (and it isn’t), and if the new option contains the same basic ingredients as the meal already in front of me (and it does) and if it has the potential of being slightly more palatable to taste (and it does), then I’m open-minded about it being served to me and maybe even slightly curious as to its potential to be better than what I’ve already been subjected to.

And that, dear friends, is how this libertarian remains open-minded about Obamacare. We’ll be able to tell in about a year if it’s better or worse, but I’ll go out on a limb and say it couldn’t be much worse than the meal we’ve been served until now.


* It’s worth noting that every health care system pools risk, or ‘redistributes wealth’. Whether by insurance pool or tax pool, the healthy majority pay for the care of the sick minority. The differences are smaller than we sometimes pretend. And under the status quo, providers raise the costs for the majority to compensate for not getting anything from people who can’t afford to pay. It appears we’re in this together, whether we want to emphasize the freedom of the individual or not.
† Health care is a perfect example of this, because it’s very clear that the public-private recipe in America is not producing the practical results of a completely universal health care system. We know this because countries that have a universal health care system are ranked much more highly than countries which do not. France, for example, tops the list at number 1. They have higher life expectancy, lower infant mortality, higher customer satisfaction, high patient success rates, much lower costs, and – despite their doctors not making the arguably insane salaries that U.S. doctors do – there appears to be no shortage of doctors or medical personnel. Sometimes if you can’t have the government-free solution you want, it’s better to go all the way than to half-ass it.