What is it about health care policy that is so difficult and destructive for Democratic administrations?

In the Clinton era, his presidency was almost undone by “Hilarycare,” the health care overhaul that was led by Hilary Clinton. A perfectly reasonable plan, it was viciously opposed by the for-profit health care industry, and sank in a storm of criticism and suspicion.

Obama was determined to learn the lesson of Hilarycare — but got an important part of that lesson wrong. Obama did two things differently from the Clintons: First, he cut a deal with the health insurance industry, promising them more healthy customers through an individual mandate to buy insurance, in return for their support and modification of their plans requiring the industry to insure people with pre-existing medical conditions. Second, he left the development of the health care reform law to Congress, rather than developing it mainly in the White House and then presenting it to Congress as a done deal. With the health insurance industry and all the Democrats in Congress on his side, Obama got his Affordable Care Act passed into law.

BUT: Obama forgot another key lesson that may sink his plan. Americans are uncomfortable with changes to their health care plans. America is unique among rich democracies in never having had a national, government funded universal health care system. The government does provide state-funded health care for certain groups: the poor (Medicaid), the elderly (Medicare) and veterans (VA hospitals and care networks). But most Americans’ get their health care through their employers via workplace health care plans, or through the purchase of private insurance. This means that most Americans regard health care as something they EARN at work or PAY FOR themselves; so it is personal. It is theirs and theirs alone and no one better mess with it unless they can provide something better.

Both Hilarycare and Obamacare share the same perhaps fatal flaw — they regard Americans’ attachment to their current health care system as a matter of ignorance. Health care reformers KNOW that their plans are better than the current, overly expensive and poor coverage system. And they are right. But they CANNOT presume to simply dictate to the public or insist that “they know better.” The phrase that worried me most about Obamacare was the administration’s insistence that Americans might not like the law or what they have heard about it, but they WILL like it ‘once they get to know it.’ That is, once we force it on people, they will discover they like it.

To say that is a highly risky, likely-to-fail strategy for any legal reform is an understatement. If you follow that route, you had better make sure, DAMN SURE, that when people encounter the policy it smells like a rose, works like a charm, and IS in fact better, in a direct and easy-to-experience way, than what people have been used to.

The roll-out of the web-site for Obamacare has been a major disaster, not just because it didn’t work well, but because it puts at risk the credibility and honesty of the administration. They have now been exposed as incompetent at best, and liars at worst.

Particularly galling — horrifying from the point of view of a case study in public policy — is what happened to the millions of Americans who had purchased bare-bones but inexpensive personal health coverage. Yes, this coverage is flawed: it often doesn’t cover what you expect if you have a moderate injury or illness, you can lose it altogether if you develop a chronic condition, and service can be poor. It is really only good for catastrophic emergency care that you hope you will never need. But for younger, healthy people who have to purchase their own insurance, it is often an appealing option in terms of cost and perceived risk.

The Obama administration must have known that such policies would become illegal under the Affordable Care Act rules. But they reasoned (1) this only affects a few million people, not the tens of millions insured through employer-paid workplace plans, and (2) with the system of subsidies provided under Obamacare, individuals who had problems with affording better coverage would be able to buy a better insurance plan for the same or less cost than the plans they had now, and (3) any others who fell between the cracks would be covered by the expansion of Medicaid to help lower-income but not truly poor people afford a decent insurance plan. So they flat-out lied when they promised everyone that “if you like your current insurance plan, you can keep your insurance; if you like your current doctor you can keep your current doctor,” knowing that while that might be true for 80% of Americans, it was not true of everyone.

So what has happened in practice? As expected, millions of people with bare-bones low-cost health care policies have received notices saying those plans will not be available after January 2013. But those people — exactly the group essential to sign up for the Obamacare insurance pools to have them include younger and healthier individuals — are being shut out of buying individual policies, subsidized and otherwise, through Obamacare because the web-site is unmanageable. As a result, the law looks like it will force millions of people out of having any kind of health insurance, the exact opposite of what was intended, and promised, by the administration.

In addition, many of those people who were supposed to be picked up by the Medicaid expansion — and that is additional millions of people — are going to be left out in the cold. This is because many Republican states refused to cooperate and accept the Medicaid expansion, once the Supreme Court said the law cannot force them to do so. So these additional millions will not qualify for health insurance subsidies NOR Medicaid, and will likely end up uninsured altogether.

The result? Due to implementation failures that were not anticipated, more people are likely to be harmed by Obamacare than helped; the administration is shown to be unable to fulfill its pledges and thus suspected of dishonesty and deceit.

Unless this is somehow fixed — and that means an easy and rewarding experience in finding insurance through the government; a plan to provide for the people in states that are not expanding Medicaid; and a sure way for  people whose policies are being withdrawn or cancelled to obtain equal or better coverage at equal or near equal cost — the credibility of the Administration is likely to collapse, destroying its ability to accomplish anything for the rest of the term, and handing a huge victory in the 2014 mid-term elections to the Republicans.

Can it be done? I do not know. But this administration has often had a tin ear in dealing with Congress or in understanding the concerns of the American people. It is now paying the price. I worry that it may continue to pay for the next three years.