For better or worse, President Obama's health care reform bill is now law. The Patient Protection and Affordable Care Act represents the most significant transformation of the American health care system since Medicare and Medicaid. It will fundamentally change nearly every aspect of health care, from insurance to the final delivery of care.
The length and complexity of the legislation, combined with a debate that often generated more heat than light, has led to massive confusion about the law's likely impact. But, it is now possible to analyze what is and is not in it, what it likely will and will not do. In particular, we now know that:
* While the new law will increase the number of Americans with insurance coverage, it falls significantly short of universal coverage. By 2019, roughly 21 million Americans will still be uninsured.
* The legislation will cost far more than advertised, more than $2.7 trillion over 10 years of full implementation, and will add $352 billion to the national debt over that period.
* Most American workers and businesses will see little or no change in their skyrocketing insurance costs, while millions of others, including younger and healthier workers and those who buy insurance on their own through the non-group market will actually see their premiums go up faster as a result of this legislation.
* The new law will increase taxes by more than $669 billion between now and 2019, and the burdens it places on business will significantly reduce economic growth and employment.
* While the law contains few direct provisions for rationing care, it nonetheless sets the stage for government rationing and interference with how doctors practice medicine.
* Millions of Americans who are happy with their current health insurance will not be able to keep it.
In short, the more we learn about what is in this new law, the more it looks like bad news for American taxpayers, businesses, health-care providers, and patients.
Bill Clinton promised to "end welfare as we know it." Alas, he has not. Despite the 1996 Welfare Reform Act, the modern welfare state is still fundamentally intact.
In this book, The End of Welfare: Fighting Poverty in the Civil Society, Michael Tanner argues that that must change. He contends that government welfare programs have failed to accomplish their ostensible goal of alleviating poverty and, moreover, they have undermined the traditional American principle of voluntarism. The interventionist welfare state has replaced civil society with political society and the results have beendisastrous.
Tanner traces the history of welfare programs and finds many of them rooted in the Progressive Era. Although those programs had modest beginnings — for example, the Children’s Bureau’s first annual budget was only $25,640 — they nonetheless laid the groundwork for the New Deal and the Great Society, which expanded government assistance programs enormously. Indeed, the author points out that the welfare state has ballooned to such a level that in "40 states welfare pays more than an $8.00-an-hour job. In 17 states the welfare package is more generous than a $10.00-an-hour job." Clearly, the system is in need of major revision. But both conservative and liberal critics have misunderstood what needs to be done, writes Tanner.
Liberals often claim that increased funding for job training and child care coupled with an expansion of the earned income tax credit would help many leave the welfare rolls. But, Tanner argues, there is little evidence to support such assertions. For example, "Not only do job-training programs fail to move significant numbers of people from welfare to work, they may actually have the opposite effect — moving people from work to welfare. Since individuals may be eligible for training programs only if they are on welfare, it becomes a rational decision for low-income working people, currently making a marginal living, to quit work and enter the welfare system."
Conservatives, on the other hand, frequently push for the establishment of "workfare" programs and support block grants. Those programs, Tanner argues, are also flawed. Workfare "does not address the most serious social consequence of welfare — children growing up in single-parent families." And block grants, in reality, do little to return power to states and local communities.
In contrast to liberal and conservative critics, Tanner argues that welfare "cannot be reformed." Instead, it "is time to end it" and to finally realize that state-supported efforts to cope with poverty are doomed to failure. In place of government programs, Tanner proposes a two-pronged approach. First, undo the shackles of regulation and taxation that have been placed on the economy and allow it to grow, thereby providing jobs for those who are able to work. And second, rely on private charities to aid those who can’t work or are temporarily between jobs.
Private charities, Tanner argues, "are far more effective than government welfare programs." They "can individualize their approaches and target the specific problems that are holding people in poverty. They are also much better at targeting assistance to those who need it most and at getting the most benefit out of every dollar."
The United States, Tanner writes, must rediscover the approach it employed during the first 130 years of its existence. It must rediscover civil society.