The thing is, such better-than-nothing-but-pretty-bad solutions have become the norm in American governance. As Steven Teles of Johns Hopkins University put it in a recent essay, we’ve become a “kludgeocracy.” And the main reason that is happening, I’d argue, is ideology.

To see what I mean, look at the constant demands that we make Medicare — which needs to work harder on cost control but does a better job even on that front than private insurers — both more complicated and worse. There are demands for means-testing, which would involve collecting all the personal information Obamacare needs but Medicare doesn’t. There is pressure to raise the Medicare age, forcing 65- and 66-year-old Americans to deal with private insurers instead.

And Republicans still dream of dismantling Medicare as we know it, instead giving seniors vouchers to buy private insurance. In effect, although they never say this, they want to convert Medicare into Obamacare.

Why would we want to do any of these things? You might say, to reduce the burden on taxpayers — but Medicare is cheaper than private insurance, so anything taxpayers might gain by hacking away at the program would be more than lost in higher premiums. And it’s not even clear that government spending would fall: the Congressional Budget Office recently concluded that raising the Medicare age would produce almost no federal savings.

No, the assault on Medicare is really about an ideology that is fundamentally hostile to the notion of the government helping people, and tries to make whatever help is given as limited and indirect as possible, restricting its scope and running it through private corporations. And this ideology, at a fundamental level — more fundamental, even, than vested interests — is why Obamacare ended up being a big kludge.

In saying this I don’t mean to excuse the officials and contractors who made such a mess of health reform’s first month. Nor, on the other side, am I suggesting that health reform should have waited until the political system was ready for single-payer. For now, the priority is to get this kludge working, and once that’s done, America will become a better place.

In the longer run, however, we have to tackle that ideology. A society committed to the notion that government is always bad will have bad government. And it doesn’t have to be that way.