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There Is No Republican Plan

[ 101 ] July 3, 2012 |

For reasons Dean Baker explains, the plan David Brooks touts as an alternative to the ACA is utter crap, a combination of stuff that’s already in the ACA (“skin in the game”) and really, really horrible ideas that will brutalize poor people while making the system less efficient (privatizing Medicaid.) There’s also a whole mess of federalist nonsense, which is particularly appalling given the vivid demonstration we’re getting that the “flexibility” many of our glorious laboratories of democracy want is the “flexibility” to deny the non-affluent access to medical care.

But there’s another con Brooks is running — describing the awful plan he finds “compelling” as a “coherent Republican plan.” Omitted are the names of any Republican legislator who supports the Republican alternative, for the obvious reason that the actual Republican alternative is “nothing.” Republicans have, of course, been engaging in this con for decades. And, pathetically, the only people more likely to fall for the scam than conservative pundits are leftier-than-thou ACA critics. I don’t know how many times I’ve seen the ACA referred to as a “Republican plan” or a “Heritage Foundation plan,” although 1)no national Republican has ever made any effort to implement this “Republican plan” including during the extensive times when they’ve controlled both houses of Congress, and 2)the Heritage Foundation fellow I debated argued that the “Heritage Foundation plan” was both horrible policy and completely unconstitutional. But I’m sure he’s been fired for insubordination!

…more here.

Comments (101)

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  1. JP Stormcrow says:

    Plan!? There ain’t no plan!

    (Couldn’t find a decent quality version.)

  2. rea says:

    There’s some econ 101 folly in there, too, that Baker doesn’t really discuss. The idea is that if we cut the amount of money the federal government puts into health care, prices will fall–because nobody will be able to afford health care at the old price–and the amount of money the federal government puts into health care will turn out to be enough. They’ve always been a bit shaky on this notion of supply and demand . . .

    • Cody says:

      That’s crazy, health insurance companies will see people dying and cut into their profits to help out.

      They’re people too, you know!

  3. Jesse Levine says:

    You must need a lot of filler today. After a series of thoughtful and interesting articles on ACA, was it really necessary to take a gratuitous swipe at liberals who don’t thnk ACA goes far enough? Nobody on the left has “fallen for the con”, it’s those pushing for the plan who use the alleged Republican origin of the mandate as a political talking point.

    • Bill Murray says:

      it’s more of a bonus for Scott. I believe he came in third at the hippie punching nationals

      • Anonymous says:

        A decade ago “hippie punching” very nicely captured a particular kind of nasty warmongering discourse designed to stigmatize and delegitimate anyone reluctant to climb on board with GWB’s Iraq adventure. It’s unfortunate that it’s become little more than a shield for the thin-skinned to dismiss any intra-left criticism.

        • Lit3Bolt says:

          Speaking of thin skins…

        • Heron says:

          It’s funny that you say that, because Mr. Lemieux only brought up the topic to make the incredibly specious argument that intra-left criticism of the ACA plays into the republican “con”, though he doesn’t specify how, exactly, they do that, or why such a belief would even matter. Apparently, while what national politicians say on television and in endless campaign commercials has absolutely no effect on anyone’s opinions and is largely just a waste of time and money, what random nobodies on the internet write in intemperate political rants has a dire impact on US national politics and the viability of the Democratic party.

          • Furious Jorge says:

            It’s the Inverted Bully Pulpit, which was a move that Andre the Giant made famous back in the day.

          • Bijan Parsia says:

            Apparently, while what national politicians say on television and in endless campaign commercials has absolutely no effect on anyone’s opinions and is largely just a waste of time and money, what random nobodies on the internet write in intemperate political rants has a dire impact on US national politics and the viability of the Democratic party.

            What? I don’t see where that follows from anything Scott’s written or even the fact of the writing.

            I spend quite a bit of time trying to refute people on e.g., this blog, but not because I think their being wrong has a measurable impact on the election (if only since, oddly enough, people don’t take my refutations on board and modify their beliefs!). I do it because I enjoy thinking about the issues and I hope, sometimes, that other people find the discussion helpful.

          • Scott Lemieux says:

            Who the hell is saying that it matters? I’m saying the argument is stupid, not that it affects votes in Congress.

            • scott says:

              You were the one making the dumb argument. Maybe they’ve backed away from it since, but yes, Virginia, the Heritage Foundation and prominent Republicans endorsed in the 1990′s a version of HCR similar in many ways to what we wound up with in ACA. (See link below) Why pointing out this bit of history makes anyone leftier than thou or some sort of cosmic dupe escapes me.

              http://www.pennlive.com/editorials/index.ssf/2012/03/ironic_challenge_affordable_ca.html

              • Yes, we’re all aware that Heritage is the genesis of the broad outline of the law, but the point is that Heritage formulated this “plan” as a tactical ploy during the Clinton healthcare push, and it’s not actually something that Heritage or anyone else on the right supports at all.

              • Scott Lemieux says:

                You were the one making the dumb argument. Maybe they’ve backed away from it since, but yes, Virginia, the Heritage Foundation and prominent Republicans endorsed in the 1990′s a version of HCR

                No, you’re missing the point — you’re still falling for the con. These plans were a decoy. “Endorsements” when you need to pretend to have an alternative when you oppose all health care reform are less than meaningless. Did Republicans try to pass them when they controlled Congress? So they backed off when something like it might actually pass, what does that tell you?

                • We should start calling EFCA the Blanche Lincoln plan for labor policy.

                • Mark Jamison says:

                  It is the absolute perfect example of goal post moving. Republican think tanks tout plans that they know will not receive serious backing as a means of diverting argument. It’s merely rhetorical jujitsu.
                  Then, every blue moon or so, when those on the left engage as if this was a serious dialogue the Right undermines their own plan. So the Heritage Foundation finds Constitutional flaws in their plan when people were dumb enough to take them earnestly and McConnell ends up filibustering his own bill.
                  Even Right leaning economists are saying now that cutting tax rates has reached a ludicrous point. But watch, the rules will change and the goal posts will move.
                  The Right is about reversing the New Deal. They’ve pretty much decimated the Wagner Act. Social Security and Medicare are the big enchiladas left on the table and they will say or do anything that keeps those programs in play.

          • Hob says:

            It seemed pretty clear to me that Scott, in this post, said that about one specific left criticism of the ACA: the idea that it’s contaminated with Republicanism because the Heritage Foundation proposed something similar. I’ve certainly heard a fair number of people saying things like “Is this the best we can do, a Heritage Foundation plan?” or holding that up as evidence that Obama is no true liberal. Regardless of whether that’s a common enough opinion to be worth attacking, I agree that it’s dumb– I don’t know how anyone who lived through the ’90s and ’00s could think the Republicans had any intention of ever passing any kind of health reform.

            • United New Left Opposition says:

              Only an enemy of the proletariat would would waste time arguing over the clear origins of the mandate.

              True servants of the people
              should be educating the workers about how many of the provisions in PPACA could have been passed in 1994, as they attempt to free them from their false care act consciousness.

              The vanguard will note the increasing toll health care costs and bureaucracy have taken on workers during the intervening generation while pointing out the inherent flaws of relying on private insurers and vulnerable subsidies to provide a basic human right.

              Working to revolutionize America’s healthcare system through earnest comments is a difficult task. One most overcome the bloggeoisie and their attempts to obstruct progress with endless critiques of bully pulpits and willpower. (Also the dastardly distractions of cat photos and music debates) We must focus on the treachery of the plutocrats and their neoliberal enablers in every thread if we are to prevail.

        • Halloween Jack says:

          Unfortunate, but probably inevitable.

    • Anonymous says:

      was it really necessary to take a gratuitous swipe at liberals who don’t thnk ACA goes far enough?

      Scott is on record as saying the ACA doesn’t go far enough as a matter of policy, so I think you’ve rather badly misinterpreted what’s going on here. The “swipe” is at those who push the “Obama enacted a republican plan!!!” line. Anyone dumb enough to take the Heritage foundation at their word (or hackish enough to pretend to) deserves this and more.

      • Scott Lemieux says:

        Particularly those who argued that Obama/Reid/Pelosi obviously could have gotten far more because this was just a “Republican plan” (albeit the kind of “Republican plan” that gets zero votes from actually existing Republicans.)

        • scott says:

          This really does boil down to the shifting Overton window. Are the Republicans of today the Republicans of 20 years ago who proposed a reform similar to ACA that would try to hold down costs and make private health care a bit more affordable? Obviously, no. So what? OK, I concede – the ACA is not a crazy modern Republican “let them die” plan, it’s an older Republican plan desperately trying to prop up the same private health care market that’s failed for the last 70+ years and make it a little more universal and a little more affordable. I’m also not sure why I should feel better that they offered that plan 20 years ago in bad faith – yeah, they were lying their asses off when they proposed this to stave off genuine reform, but we sure called their bluff by enacting it! I feel less like they’re conning us and more like we’re conning ourselves when we engage in a heated debate about whether a reform proposed by Republicans and actually signed off on by Mitt Romney is Republican.

          • Um, if we’re calling something that no Republicans support and that resides firmly within the center-left of actually existing American politics “the Republican Plan,” isn’t that shifting the Overton Window quite dramatically to the left?

          • Scott Lemieux says:

            Are the Republicans of today the Republicans of 20 years ago who proposed a reform similar to ACA that would try to hold down costs and make private health care a bit more affordable?

            No, but this doesn’t change the fact that Republicans of 20 years ago didn’t support this plan either. This isn’t a hypothetical — they controlled Congress!

            On a side point, it’s possible that the phrase “overton window” could be part of an argument that understands something about how American politics actually works, but this possibility is becoming increasingly theoretical.

      • Walt says:

        But Obama did enact a Republican plan, one not incredibly far from the plan enacted by his upcoming Republican opponent while governor of Massachusetts.

        • djw says:

          It was a law passed by overwhelming Democratic legislatures. Romney went along with it in part because he knew they’d pass something over his veto if he didn’t cooperate. So this is pretty misleading too.

        • Scott Lemieux says:

          Yeah, a plan reluctantly signed by a Republican governor in a liberal state after it was passed by Democratic supermajorities — that totally indicates what Mitch McConnell would sign off on. I’ll bet he supports most of John Lindsay’s economic and social agenda too.

          • Jesse Levine says:

            I think you’ll need to explan who John Lindsay was. I was the Liberal Party Queens County campaign chairman in the ’69 election. Your last comment has me confused as I don’t know the history. Do you mean that the Mass plan originated with Dems?

            • Scott Lemieux says:

              I mean it the plan has absolutely no support from national Republicans, which is what is under discussion, and the legislation that a Republican governor in one of the bluest states in the country will sign when faced with Democratic supermajorities is about as relevant to what national Republicans support as what policies were supported by 60s-vintage liberal Republicans like, say, John Lindsay.

              • Walt says:

                Really, national Republicans are against Obamacare, have campaigned against it, and are promising to repeal it if they get the chance? I missed that.

                • Scott Lemieux says:

                  Indeed. Perhaps you can then explain how this set of facts can be compatible with the claim that the ACA is a “Republican plan.”

                • Walt says:

                  Would today’s Republican party vote for Medicare Part D if it was an Obama initiative? And if no, does that make Medicare Part D not a Republican plan?

                • Bijan Parsia says:

                  Part D is an interesting case, but if you look at the whole bill, and particularly at Medicare Advantage (not to mention health savings accounts and the privatization pilot) and we do see something pretty close to a standard Republican plan…and it doesn’t look like the ACA.

                  While opposing whatever Obama does or might like in any manner is, of course, the overriding principle of modern Republicans, it’s hard to see that universal coverage was something they were remotely interested, ever. Cf 2 Bush vetos of SCHIP expansion.

                • standard says:

                  Of course Medicare Part D is a Republican plan.

                  1) $600 B program benefiting the demographic most likely to vote Republican

                  2) prohibited negotiating drug prices to help their PHRMA friends

                  3)knowingly false information used to sell plan while concealing true cost

                  4)no dedicated financing
                  so cost simply added to the budget deficit

            • Malaclypse says:

              It was massively expanded by the Dems. Romney had no employer mandate. JFL probably remembers the details better than me, but “Romneycare” was basically only the individual mandate, plus some inadequate subsidies, and a pool to get group coverage rates.

          • gmack says:

            Forgive me if I am missing the point here, but isn’t it true that the rhetorical move on the left that asserts that the ACA isn’t terribly liberal because it was originally a Heritage Foundation plan is designed to dramatize a position that you also accept: namely, that the ACA isn’t great policy and doesn’t go far enough? We are all disappointed in the lack of a public option and that our institutions make it so wankers like Lieberman or Evan Bayh can scuttle reforms. Thus, noting that the plan actually has several conservative components might be a way of establishing it rhetorically on the center-right of the political spectrum, as opposed to where it is usually located now, on the “radical left.” Such a positioning might then help make more left-leaning policies (e.g., the public option) gain a hearing. In other words, it seems to me that most leftists who hammer the Republican origins of the ACA do not think that current Republicans will support any health care reform plan; the goal, rather, is to label the plan as Republican, which (a) might allow the public option to appear as the center-left option, and (b) prepares the argument needed to label existing Republicans as unprincipled and radical obstructionists who won’t even agree with their own proposals.

            I’m of course dubious that things will work out this way, but I’m failing to understand why it is so essential to reject the kind of rhetorical moves that leftists make when they highlight that the ACA was originally a Republican plan.

            • Bijan Parsia says:

              I think it’s fine if it’s a tactical move designed to help highlight the problem with the Republican party and/or to try to otherwise gain acceptance of PPACA. I’m not convinced it does all that much good: Everything true about Republicans is projected on to Democrats, plus baby eating.

              The objection is to using it in intra-left disputes as if the “Republican plan” was a sincere policy desire of any substantial portion of the current Republican party.

              • Hogan says:

                And therefore evidence that Obama, Reid and Pelosi are crypto-Republicans.

                • Bijan Parsia says:

                  Exactly.

                  I’m sad that bylines have petered out. Clearly an internet tradition without legs. (Like the lovely “don’t project your artifice” one.)

                  Bijan Parsia
                  WEST ARTIFICE PROJECTION, NJ

                • Walt says:

                  So we need to deny the actual historical record to take a talking point away from leftists?

                • Bijan Parsia says:

                  Not at all.

                  I think it’s fine to point out the truth that the mandate notion was put out there by the Heritage foundation and nominally supported by tons of Republicans and signed into law by Mitt Romney.

                  But it’s silly to go from there to the ACA being some sort of minimal common position such that, say, McCain + Republican congress would have passed it, or that we could have gotten something like a public option through (after all, Collins at one point said she considered it!).

                  The Republican plan, by and large, was no useful health care reform and especially none aiming at universal coverage. They were pretty consistent about that since at least the Clinton years.

                • Walt says:

                  Does anyone think this? I’ve never heard the argument that McCain plus a Republican Congress would have passed the ACA, but I lead a sheltered existence.

                • bradp says:

                  I can’t say that I have read anyone describe what they think a McCain administration would have done differently.

                • Bijan Parsia says:

                  Sorry, the McCain bit was an somewhat hyperbolic invention for just for illustrative purposes.

                  Hmm. I went looking for some examples of this line and my searching is finding mostly the hypocrisy pitch (which is good!). (See this!)

                  So, I’ll leave Scott to supply the particular examples and leave my posts as more hypothetical til then.

                • Hogan says:

                  So we need to deny the actual historical record to take a talking point away from leftists?

                  Not a tall. We just need to see it steadily and see it whole.

                • Malaclypse says:

                  I can’t say that I have read anyone describe what they think a McCain administration would have done differently.

                  Good news! Google is a thing that lets you look things up.

                • Scott Lemieux says:

                  So we need to deny the actual historical record to take a talking point away from leftists?

                  I think we should affirm the historical record. Which is that the federal Republican Party has been completely opposed to any version of comprehensive health care reform for many decades.

                • Walt says:

                  And part of that opposition was to propose a plan with elements similar to the ACA. Hence the term “Republican plan”.

                • Bijan Parsia says:

                  Right. And in that sense it totally is a Republican plan. In the sense of it being legislation that Republicans want to see enacted, it is not.

                  Contrast it with the Ryan plan which is all smoke and mirrors and they totally would vote for, push, etc.

                • This. If anything, more precise language is needed. Perhaps something shorter than “the plan Heritage disingenuously formulated to muck up the political waters in 1994,” but simply calling something that no federal Republican office holder supports or has made any effort to enact into law during a period of unified Republican control (health savings accounts ftw!) “the Republican plan” is much more distorting than anything else.

            • Sly says:

              Thus, noting that the plan actually has several conservative components might be a way of establishing it rhetorically on the center-right of the political spectrum, as opposed to where it is usually located now, on the “radical left.”

              I would accept this argument if it had any traction in our mainstream political discourse. As it stands, however, you only hear this argument in exclusive congregations of the left. So I’m not inclined to see this as any more than a pity party internal to one, mostly insular, subfaction of liberals.

              • gmack says:

                As I mentioned in my last paragraph, I agree with this, by and large. Though it has been widely reported, I see little evidence that the origins of the ACA among some conservative groups has had much impact on anything.

                At any rate, there is no doubt that some folks on the self-styled left often make bad arguments–that Obama’s support of the ACA means that he’s a conservative, or that we should repeal and replace it, etc. Insofar as they make claims of this sort, I think Scott’s critique is well-taken. I suppose that comment arose from a puzzlement. There is no necessary connection between these bad arguments and the rhetorical move of pointing out the Republican origins of the ACA. As a result, I wasn’t sure what the point of Scott’s original critique was. For instance, in various conversations with people, I have “flogged” the conservative origins of the ACA, but not to paint Obama as a conservative, and still less to suggest that contemporary Republicans would actually support the bill if it had been proposed by McCain or Romney. Rather, I am trying to make the kind of rhetorical move I mentioned above. So I was puzzled at Scott’s criticism of those who make these arguments, a puzzlement that, I hasten to add, is now dissipated.

    • Sly says:

      After a series of thoughtful and interesting articles on ACA, was it really necessary to take a gratuitous swipe at liberals who don’t thnk ACA goes far enough?

      It is always necessary.

      There are four major stakeholders in the health care systems pre ACA (I use the plural because the United States has been operating under 50 different regulatory regimes for a century): Both for-profit and non-profit insurance providers, care delivers like doctors and hospitals, care “manufacturers” like DME and pharmaceutical companies, and state insurance commissioners who have regulatory “turf” that they’ll institutionally want to protect.

      All of these stakeholders will invariably see reform of the system(s) as a threat, the degree of which varies on the type of reform under con sideration. Single payer, for instance, will (a) put every insurance company, for-profit and not-profit, out of business, (b) force care providers and “manufacturers” to negotiate solely with the Federal government over price, and (c) usurp what has been the domain of state ICs. They are not going to like that, they are going to fight against it, and they would not feel constrained to fight under the Marquis of Queensbury rules typically favored by those who naively romanticize democratic power.

      You have to undermine those stakeholders, and flowery political rhetoric will not be effective. And neither, certainly, will be ignoring them and hoping that the consciences of politicians who have to raise money to keep their jobs will win the day. You either have to co-opt their interests, coerce their acceptance, run them over (if they’re weak enough), or simply buy their cooperation. And the political strength of these various stakeholders is such that you simply can’t try to run over all of them simultaneously and expect to succeed.

      You have to pick your battles. The ACA retreats in some areas and advances in others and does so in a way, I would argued, that advances the war. The “we could have gotten something better so this whole effort was worthless” line from the left is nothing more than a general retreat, argued under a grave misapprehension of how political change actually occurs. The only difference between it and the “Repeal and Replace” mantra mouthed by the right is that the latter is pure cynicism.

      • Scott Lemieux says:

        Right, the de facto leftier-than-thou plan is exactly the same as the actual Republican plan: nothing. Only with the Republicans they at least know what they’re doing.

      • Bijan Parsia says:

        Note that this was true, as I understand it, of the NHS. There, the big group to buy off was the GPs. But they stayed bought. I think the crazy Tory plan is basically that playbook (GPs in charge, not the trusts!) but the GPs aren’t falling for it.

        • Sly says:

          Note that this was true, as I understand it, of the NHS.

          This is true of virtually every major political, economic, and social reform ever gained through legislative action. The only one off-hand that might have been accomplished through sheer brute-force activism was Women’s Suffrage, and I’m only saying that because I’m less familiar with its historical development compared to other reforms.

          One of the problems the left has is that it is too much in love with its own history; because it romanticizes democratic power, it recasts every hard-fought battle it has ever won as being won through sheer political will. It doesn’t work like that, never has, and its why the designation of this dogma as “Green Lanternism” is so thoroughly apt. This fantasy can blind the left, and has blinded it, to ways in which it can achieve measurable progress, and this is what so frustrates the rest of us.

          In terms of the ACA, the Democrats basically bought off the Pharmas and the State ICs while putting together the ACA. The Pharmas were given some juicy benefits with respect to patents, and the State ICs were given local administration over the state exchanges. The reason we’re going to have state exchanges and not one national exchange is, I’m certain, entirely due to the lobbying of the National Association of Insurance Commissioners.

          Where I think the left gets it wrong is believing that the mandate effectively bought off for-profit insurers. The way the ACA approached the insurance industry, broadly speaking, was through a strategy of divide and conquer; divide the for-profits from the non-profits through reforms like MLRs and guaranteed issue that will strengthen the non-profit sector. Vermont basically did the same thing with their own reforms a decade ago. Plus, every state exchange is mandated to provide non-profit options, so the notion that people are being forced to buy policies from vampiric squids like Anthem and WellPoint is not true.

          The providers were won over through a negotiated settlement; there will be some cost controls (and yes, I would agree that they are mostly nebulous and unproven), but no big cost controls. What got the Medicare buy-in and the public option killed wasn’t for-profit insurers, it was the Federation of American Hospitals and the AMA. And for the simple reason that many providers, particularly the ones with large coffers to spend on lobbyists, don’t want to be forced to negotiate with the Feds on prices.

          • Halloween Jack says:

            One of the problems the left has is that it is too much in love with its own history; because it romanticizes democratic power, it recasts every hard-fought battle it has ever won as being won through sheer political will. It doesn’t work like that, never has, and its why the designation of this dogma as “Green Lanternism” is so thoroughly apt. This fantasy can blind the left, and has blinded it, to ways in which it can achieve measurable progress, and this is what so frustrates the rest of us.

            This, so freakin’ hard.

  4. catclub says:

    I agree that there was nothing there. Scorched earth politics demanded it. But if something like that had been offered — with GOP votes accompanying, Obama would have jumped for it.
    As would Max Baucus and Lieberman.

    The key nothing was when it mattered – 2009.

    The thing Brooks is swooning over now, an individual market with regulations (i.e. the exchanges) is what we have now for everybody who does not have employer based health insurance.

  5. Walt says:

    I have the impression that this is a typical Brooks maneuver, that he’ll hold up an actual policy the Democrats are advocating as the “sensible middle” that both Democrats and Republicans are too unreasonable to adopt. I can’t think of another example, though, just because I try to forget everything Brooks says as soon as I hear about it, to reserve space for more important things like hockey scores.

  6. Steve S. says:

    leftier-than-thou ACA critics. I don’t know how many times I’ve seen the ACA referred to as a “Republican plan” or a “Heritage Foundation plan,”

    I don’t know how many times I’ve seen center-left ACA supporters harping on this, in an attempt to highlight conservative hypocrisy. Far more than the left-left, as a matter of fact. Barack Obama, for instance.

    • John says:

      You really haven’t seen left-lefties going on about how terrible the ACA is because it was a “Republican plan”?

  7. bk says:

    Why anyone even reads the crap that Brooks spews out is beyond me.

  8. jeer9 says:

    As Warren Terra mentioned in an earlier thread, “the PPACA promises to regulate insurance companies, to make them more reliable and transparent, to make competition among them more effective – in effect, even without a Public Option the long-term effect should be to turn them into docile Public-Private Utilities. And Utilities are fundamentally boring and predictable, and don’t offer the scope for ambition and profits available to them under their current freewheeling lifestyle.” That’s the ideal outcome.

    Angell and others, however, have asserted repeatedly that the PPACA contains no cost controls whatsoever. And according to the 2011 report of the Massachusetts Attorney General, their health care “reform” hasn’t decreased the cost of health care in that state one bit. In fact, overall health care costs in Massachusetts are up by 6% compared to nearby states. Employers appear to be shifting the burden of paying for health insurance increasingly to workers because health insurance premiums are rising so fast employers can’t afford to pay them. There are numerous other difficulties associated with this type of approach at the state level that have not been fully addressed, and it remains to be seen (despite the loud clapping) whether the federal model mitigates or exacerbates them.

    Just because no elected national Republican official/contingent has ever pushed for health care reform in its Heritage Foundation version doesn’t mean that this particular approach is ultimately good or effective (or anything more than weak rightwing sauce, even if it was all that could have been passed.) It just means that Republicans don’t care about solving any problems from military spending to financial reform to global warming – which is hardly breaking news. They wreck things, and the Dems try half-heartedly (or as much as conservadems will allow) to repair the damage. Rinse. Repeat.

    The good news seems to be that Massachusetts citizens like the law, despite its many apparent flaws, which in the political realm is half the battle.

    • Bijan Parsia says:

      Angell and others, however, have asserted repeatedly that the PPACA contains no cost controls whatsoever.

      Is this really true? Or are they using a very specific notion of cost control?

      There are all sorts of measures which are intended to lower costs, as I recall, e.g., shifting from fee for service to fee for outcome (which is already lowing costs in many areas).

      One thing I do know is that recent research shows that preventative care doesn’t seem to lower lifetime costs (since people who live longer often end up sicker longer). Similarly, costs go up as coverage expands as the newly covered start using their insurance. But those seem ok to me.

      • jeer9 says:

        But the Massachusetts plan, which has been in effect for five years, is rapidly becoming unsustainable. Health care now consumes 43 percent of the state budget, a percentage that has been growing, while expenditures on every other budgetary category—including education, human services, infrastructure, law, and public safety—have been shrinking. Although Massachusetts began with advantages the rest of the country doesn’t have—an already high rate of insurance and a large “free care pool,” provided by hospital and insurance fees, that was tapped to subsidize the new plan—it is still unable to afford it.

        The legislature is now trying to contain costs by devising new payment methods for providers, while insurers are raising premiums, deductibles, and copayments. The problem in Massachusetts is that there was no way to control the costs of an inherently inflationary reform, just as there isn’t in the ACA. Massachusetts should be seen not as an inspiration, but as a warning.

        Angell, June 7th, NYRB

        • Bijan Parsia says:

          Ok, I agree that they assert that. But, that assertion doesn’t seem to be true:

          The Affordable Care Act’s central hope is that Medicare can lead the health-care system to pay for value, cut down on overtreatment, and cut out treatments that simply don’t work. The law develops Accountable Care Organizations, in which Medicare pays one provider to coordinate all of your care successfully, rather than paying many doctors and providers to add to your care no matter the cost or outcome, as is the current practice. It also begins experimenting with bundled payments, in which Medicare pays one lump-sum for all care related to the successful treatment of a condition rather than paying for every piece of care separately. To help these reforms succeed, and to help all doctors make more cost-effective treatment decisions, the law accelerates research on which drugs and treatments are most effective, and creates and funds the Patient-Centered Outcomes Research Institute to disseminate the data.

          If those initiatives work, they head over to the Independent Payment Advisory Board (IPAB), which can implement cost-controlling reforms across Medicare without congressional approval — an effort to make continuous reform the default for Medicare, even if Congress is gridlocked or focused on other matters. And if they don’t work, then it’s up to the Center for Medicare and Medicaid Innovation, a funded body that will be continually testing payment and practice reforms, to keep searching and experimenting, and when it hits on successful ideas, handing them to the IPAB to implement throughout the system.

          The law also goes after bad and wasted care: It cuts payments to hospitals with high rates of re-admission, as that tends to signal care isn’t being delivered well, or isn’t being follow up on effectively. It cuts payments to hospitals for care related to infections caught in the hospitals. It develops new plans to help Medicare base its purchasing decisions on value, and new programs to help Medicaid move patients with chronic illnesses into systems that rely on the sort of maintenance-based care that’s been shown to successfully lower costs and improve outcomes

          .

          Plus health cost growth has declined recently:

          Interestingly, despite all of the negative rhetoric surrounding the Patient Protection and Affordable Care Act, otherwise known as health care reform, The Segal survey found that so far the law has had minimal impact on employer health care costs. This is somewhat surprising given that one of the first elements of the law to take affect was the expansion of health plan eligibility to adult children up to 26 years of age. In fact, the survey found that 71 percent of respondents expect this coverage expansion to increase costs by less than one percent.

          So, I’m not sure what’s up. You can, of course, argue that the cost control mechanism in the ACA are inadequate or ineffective, but non-existent seems a bit much.

          • Bijan Parsia says:

            And here’s Gruber directly comparing the plans:

            The Massachusetts reform did not include much of what is incorporated into the ACA, in particular the revenue sources — reform in
            Massachusetts was financed jointly by the federal government and by an existing tax that financed care for the uninsured — and the efforts at cost control discussed above. But it does provide an excellent case study of the three-legged stool approach to covering the uninsured and fixing the non-group market.

            He also disputes the “flight from employer based coverage”:

            Second, rather than a crowd-out of private insurance through the expansion of a publicly funded entitlement, there has been a “crowd-in” through a rapidly rising rate of employer-insured individuals. According to estimates from the Current Population Survey, the share of the Massachusetts population with employer-sponsored insurance rose by 0.6 percent from 2006–2009, while over the same period the share of the national population with employer-sponsored insurance fell by 4 percent. Some of this “crowd-in” is due to increased enrollment in employersponsored insurance by those endeavoring to meet the requirements of the mandate, but some has actually been through higher rates of employer insurance offering. The rate of employerprovided insurance offering in Massachusetts rose from 70 percent in 2005 to 76 percent in 2009, while it remained flat at 60 percent nationally (Massachusetts Division of Health Care Financing and Policy, 2010). There is no obvious explanation for this increase in employer offering as the law introduces incentives for employers to drop insurance (by covering their low income employees outside the employer setting) and does little to penalize those firms that do drop coverage. The best potential explanation for this result is that there was a non-market impact of the mandate on employer behavior, with employees demanding coverage to meet the mandate and employers increasing coverage to meet the demand.

            Maybe that paper is outdated? Could you source your claims, please?

    • bradp says:

      This is a fine comment, jeer9.

      • Incontinentia Buttocks, FILLED TO THE BRIM WITH "ART" AND "THEATER" COLLEGE STUDENTS AND HIP-HOP THUGS says:

        Yup, excellent comment.

    • This seems like two different concerns though. One the one hand, you want to increase insurance coverage so that everyone has access to healthcare, on the other hand you want to reform the actual healthcare industry such that the costs of healthcare don’t continue to rise and gobble up an ever larger share of GDP. These are, however, two somewhat distinct concerns and, even though there’s no reason you can’t, or shouldn’t, attempt to do both at once, there’s also no reason that lack of the latter should cause you to ignore the former (just the opposite, in fact). But the latter is a very difficult political lift, because “lower healthcare costs” quite directly means lower profits for a lot of stakeholders, including doctors and hospitals, and is certainly vulnerable to much talk of “rationing” and what not (the fantasy that single payer achieves 120% of its savings through eliminating insurance company profit held by some notwithstanding).

      • chris says:

        If you’re not going to ration care by saying “you can’t afford care, so go die in a gutter” then you have to ration it some other way. Which is probably going to involve some sort of death panel. At least, anyone who can say “This treatment’s effectiveness/cost is too low for someone with your condition, so we’re not going to give it to you” is going to be attacked as a death panel, whoever they are. (Or maybe that should be, only if they’re a government? Because you could argue that private insurers are doing this kind of thing already and nobody calls *them* death panels.)

  9. Heron says:

    I’d say most people think it’s a Republican plan because it has been widely reported by major newspapers like the LA Times and the New York Times that the idea of individual insurance mandates was first introduced to most people commenting on politics today by Republican think-tanks, and that the ACA is very similar to the counter-offer the Rs put forward in 1993-4. I don’t know if that’s true or not because, while I can find plenty of references to this, I can’t seem to find any “primary sources” for it, though that could just be because I’ve only spent the last 5 minutes looking.

    It’s useful to point out that no Republicans have ever acted on getting such a plan passed, of course, and from there arguing that bringing up such plans were just a way to stymie heathcare reform, but bringing that up doesn’t change the origins of the concept. If people on the left feel the ACA is inadequate, shouldn’t they be criticizing it? For some reason, I think calling it the “Swiss Plan” or some other Euro equivalent just wouldn’t have the same ring to most US lefties with angry memories of the Clinton era.

    • Bijan Parsia says:

      Try starting from this article:

      The mandate made its political début in a 1989 Heritage Foundation brief titled “Assuring Affordable Health Care for All Americans,” as a counterpoint to the single-payer system and the employer mandate, which were favored in Democratic circles. In the brief, Stuart Butler, the foundation’s health-care expert, argued, “Many states now require passengers in automobiles to wear seat-belts for their own protection. Many others require anybody driving a car to have liability insurance. But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement.” The mandate made its first legislative appearance in 1993, in the Health Equity and Access Reform Today Act—the Republicans’ alternative to President Clinton’s health-reform bill—which was sponsored by John Chafee, of Rhode Island, and co-sponsored by eighteen Republicans, including Bob Dole, who was then the Senate Minority Leader.

    • djw says:

      I’d say most people think it’s a Republican plan because

      “Most people” think nothing of the sort. This particular point of view is held by a very small portion of politically aware individuals.

  10. thebewilderness says:

    The Republican “plan” has always been to deregulate the insurance industry and failing that to permit selling insurance across state lines to minimize regulations.
    To repeal the law that requires hospitals to provide emergency care.
    Tort reform similar to Texas where it costs more to bring suit than the maximum awards provide for.
    Voucherize Medicare.
    Close the VA.
    End Medicaid.

    Did I miss anything?
    I don’t know that any Republican has ever put it all on the same piece of paper and called it a plan, but those are the elements that Republicans have been promoting for a very long time.
    I don’t think any of them are included in the ACA.

  11. bradp says:

    Republican intentions when it came to passing any sort of health care reform are irrelevant. This is a right-of-center plan that kicks the can down the road. If it isn’t a republican plan, it might as well be a republican plan.

    Defend the authors of this plan as the best that could be done against complete obstructionism, but at least don’t oversell it.

    • Scott Lemieux says:

      It’s not a “right-of-center” program unless we’re dealing with the political culture of some other country, and many aspects of it contradict core Republican principles.

    • Malaclypse says:

      Reasonable libertarian Tyler Cowen has a health plan as well:

      We need to accept the principle that sometimes poor people will die just because they are poor.

  12. thebewilderness says:

    Eric Cantor says the Republican plan is the same one they put forward in 2009.

  13. Rob says:

    This will surely show that noted leftist Brad DeLong!

    • Sharon says:

      Thank you. I remember reading his blog the day after the PPACA was signed and he was quite tickled by the half gainer with a twist aspect of Congressional Democrats supporting and later passing a plan that had its origins at Heritage.

      When I voiced an intemperate opinion in his comments, he graciously took time out send me an email and to scold me. He asked me if I’d rather have the PPACA or be poked in the eye with a sharp stick.

      I took the legislative win.

  14. ploeg says:

    The basis of the ACA is a “Republican plan” in that, if the ACA had not been passed and the US health care system had become so bad that there was widespread public and elected support for single payer at a bare minimum, a half-assed (or quarter-assed) version of ACA would have been proposed as the Republican alternative. Naturally having the ACA now is vastly preferable to having a half-assed or quarter-assed ACA maybe 10 or 15 years down the road, if ever. And also naturally, just because somebody at a think tank starts gaming up what the Republicans might do when the folks with torches and pitchforks show up, that doesn’t mean that the Republicans are ever going to enact such a policy except under extreme duress.

    It is worth pointing out, however, that the more distasteful parts of ACA are there due to the need to buy off stakeholders in the current suboptimal health care system. And while said stakeholders might not necessarily be Republicans, one must always be clear that the ACA is a compromise between the Democrats and the vested interests, where the vested interests get something and the general public get something.

    • Scott Lemieux says:

      It is worth pointing out, however, that the more distasteful parts of ACA are there due to the need to buy off stakeholders in the current suboptimal health care system. And while said stakeholders might not necessarily be Republicans, one must always be clear that the ACA is a compromise between the Democrats and the vested interests, where the vested interests get something and the general public get something.

      This is certainly correct.

    • LeeEsq says:

      I agree with you second paragraph but not your first. Even if the American health care system reaches crisis level, there is little or no evidence that it will lead to widespread public and elected support for a socialized health care system. First, its unclear what crisis level would be. As long as the health insurance companies are earning enough profit, the GOP is going to argue that our system is the best in the world and oppose change. This is true even if people aren’t receiving healthcare.

      So for one political party, a crisis will not occur unless the health insurance companies are in trouble and the only acceptable solution in one that saves them. This means that there will always be opposition to meaningful health care reform.

    • Incontinentia Buttocks, FILLED TO THE BRIM WITH "ART" AND "THEATER" COLLEGE STUDENTS AND HIP-HOP THUGS says:

      Since many of those vested interests are big donors to both major parties, I think it’s wrong to describe this as a process of negotiation between the Democrats and said vested interests, as if the interests stood outside the party.

      • LeeEsq says:

        Not really, the vested interests donate to the parties to protect their interests but they are still outside of the parties as they do not partake in the day to day management of the parties.

        • Incontinentia Buttocks, FILLED TO THE BRIM WITH "ART" AND "THEATER" COLLEGE STUDENTS AND HIP-HOP THUGS says:

          They partake as much, if not more, in the day to day management of the parties as any other constituency does. There’s nobody in the current cabinet whose background in and ties to, e.g., organized labor are as deep as Timothy Geithner’s background in and ties to Wall Street.

          • Hogan says:

            The Executive Branch isn’t the party. There are elected officials who are important figures in both government and party; cabinet members generally aren’t, unless they bring some clout in with them (like Hillary Clinton or Ron Brown).

  15. eric says:

    On the campaign trail:

    “When you hear all these folks saying, ‘Oh, no, no, this is a tax, this is a burden on middle-class families,’ let me tell you, we know because the guy I’m running against tried this in Massachusetts and it’s working just fine–even though now he denies it,” Obama told about 300 supporters at Dobbins Elementary School in the village of Poland.”

  16. [...] even inept on its own terms — surely he could at least give us the ridiculous “it was a Heritage Foundation plan!” red herring. What’s an idiotic argument about how Republicans really secretly favor [...]

  17. [...] I think Chait gets the lay of the land right here. What matters to congressional Republicans is low taxes for the wealthy, period. They’ll take cuts to spending for the poor, and they’ll accept cuts to middle class programs if they can blame Democrats for them, but given the choice they would much rather have upper-class tax cuts than cuts to Social Security and Medicare. And Republicans have a “plan” to reduce tax loopholes in the same sense that the Heritage Foundation had a “health care reform” plan. [...]

  18. [...] favored by the auteur of Dow 36,000; the problem is just that it’s an AEI proposal in the same sense that the ACA was a “Heritage Foundation proposal”. That is, there’s less than no chance that any conservative think tanker or national public [...]

  19. [...] not even sure where to begin. Well, first, the ACA is not a “Republican plan” in any meaningful sense. The idea that Obama thought that health care politics would somehow transcend partisan divisions [...]

  20. [...] long-time readers know and new readers were reminded yesterday, I’ve long been intensely irritated by claims that the Affordable Care Act proves that Barack Obama is a hapless sellout because it was [...]

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