Back in 2009, the healthcare debate was more productive than this time around. Most sound and fury has been directed at the failings of the AHA (Obamacare) and whether the Republicans' proposed plan would have been "better" or "worse". That raging debate has prevented the media - and by extension, most people concerned - from looking deeper at the underlying system design issues the legislation tried to accommodate in its solution.
But until we start to honestly come to grips with these design issues, it seems highly unlikely we will see anything resembling the vision President Trump painted in the course of his election campaign.
System design is still the problem.
According to David Goldhill of The Atlantic, from the 2009 debate period:
“Indeed, I suspect that our collective search for villains—for someone to blame—has distracted us and our political leaders from addressing the fundamental causes of our nation’s health-care crisis. All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value.”
For a system to achieve its purpose - regardless of what system is being built - people in the system have to be naturally incentivized to act in accordance with that purpose. Any incongruency between system-mandated behaviors and system participants’ inherent self-interest will result in an failed system. The more incongruent these things are, the more perverse system outcomes will be.
Hopefully the political discussion can begin to reflect this logic. It would surely be helpful for the media to invest more time analyzing and presenting these underlying issues to the public. Until then, it seems unlikely election promises made can ever be kept.