Can “Government” Create Universal Health Care Now?

Matthew Yglesias writes that,

The problems with HealthCare.gov are a substantial practical problem for the Affordable Care Act and should be a real source of shame for the Obama administration [… but,] the existence of great websites is sort of incidental to the operation of a social insurance system [… and] it’s not like the underlying idea of bringing a Bismarkian health insurance system to the United States depends in some conceptual way on the website. Bismark did it in 1883!

That’s a heavily edited-together paragraph that smushes sentences together, for the record.  I do not think it mangles Yglesias’ point, but read the whole thing.

Anyhow, his point is true on its merits, but it’s also a bit (intentionally?) obtuse, and raises an interesting question.

First of all, the obtuseness.  Yglesias is responding to a tweet from Patrick Ruffini which says:

It’s so cute when the left realizes that the government isn’t competent enough to implement all their grand designs.

And Yglesias responds as though Ruffini were saying that the website problems will doom the ACA.  What Ruffini is actually saying, rightly or wrongly, is that the website problem is symptomatic of a general governmental dysfunction, the ultimate cause of which will doom the ACA, regardless of the website issue.

Second, Yglesias is correct that universal healthcare systems have been created successfully in the past.  But that does not necessarily imply that universal healthcare systems can be created successfully in the present.  For example, if you are an adult human being, you have probably heard people speculating on whether the entire modern system of driving could get off the ground if it were started today.  Would people in 2013 America be willing to accept tens of thousands of excess deaths per year, and millions of injuries, for faster transportation, if it was not presented to them as fait accompli?

2013 America is not 1883 Prussia, and the difference is not merely that we have websites, whether those websites are functional or not.  There exists at least the theoretical possibility that some things that could be accomplished in 1872 Prussia can not be accomplished in 2013 America.  I think people don’t like that, because it goes against the dialectical advancement of history deal that most of us picked up even if we discarded other parts of Marxism, but even granting (as I happily do!) that 2013 is on the whole far more capable than 1883, that doesn’t mean that it is more capable in every way.

Most notably, when the successful European healthcare systems were set up — all of them! — their governments were much smaller and perhaps more efficient than they are today.  The bureaucracies were more nimble, parasitism on them was weaker, and perhaps power was more centralized within them.

The New York Times ridiculously reported that,

According to one specialist, the Web site contains about 500 million lines of software code. By comparison, a large bank’s computer system is typically about one-fifth that size.

The specialist is wrong, and also stupid.  There are not one half a billion lines of code involved in the ACA website.  It’s just not possible.  The unnamed specialist, who should not have been granted anonymity, was either just simply factually wrong, or else using some grotesquely misleading definition of what a “line of code contained in the Web site” means.  But it probably is true that this is a horribly bloated project.  And it is probably true that a modern business of say 100 people could design a website that could handle the load that HealthCare.gov handles, more cheaply and more correctly.  It is simply the case that larger organizations tend to be less efficient than smaller organizations, and perhaps true that government tends to be less efficient than at least the top 20% or so of non-governmental organizations.

This is the case when creating websites, and it is probably also the case when designing healthcare programs.  It is possible that the US government has simply gotten too big and too inefficient to successfully accomplish what most of Europe did between 150 and 50 years ago.

I don’t put high odds on this being true.  I think that it is more or less likely that we will end up with a somewhat functional, if flawed and bloated, healthcare program after the initial troubles get slowly, inefficiently ironed out.  But the fact that Bismarck could do something in 1883 is not a reason to believe absent all other evidence that Obama can do the same thing in 2013.

Edited:  In my mind, Otto von Bismarck and the year 1872 are inextricably linked, so in an earlier version of this article, all the dates that currently say 1883 said 1872 instead.

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