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The Overdetermined Shape of Health Care Reform

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Johnathan Bernstein has an addition to my recent series of posts on health care reform:

One key point that Lemieux doesn’t mention this time: in one sense, this really isn’t about 2009 at all. It’s about 2007 and 2008, when the three leading Democratic presidential candidates converged on essentially the same plan (with Obama famously omitting the individual mandate). That says a lot. It says that none of those three candidates believed that adopting single-payer would have given them a serious edge in a closely contested nomination fight — and that no other candidate was able to leap to the top tier by embracing single-payer. In other words, it tells us that in the world of 2007-2008, at least, the ACA was mainstream within the actual Democratic Party as it was, and single-payer was a fringe position in the actual Democratic Party as it was. Maybe lots and lots of Democrats preferred single-payer in some sense, but virtually none of them, either elites or electorates, did anything about it. And that’s what counts.

What this also means is that ACA vs. single-payer had virtually nothing to do with Barack Obama himself. And so Obama-centric explanations for it are clearly, 100%, wrong.

This is right. Presidents have agency, but they lead political coalitions. In a political universe where single payer (or, more plausibly, Swiss health care) was viable, at a minimum it would have to have such powerful support among the Democratic electorate that a major presidential candidate would endorse it. This wouldn’t be enough — given its structure, the median votes in the Senate are almost certain to be well to the right of the Democratic candidate for president, let alone the Democratic primary electorate — but it would be a minimum first step. In the politics of 2008 and 2009, anybody who became a Democratic president was going to pursue comprehensive health care reform of essentially similar shape unless they decided not to pursue it all (which was highly unlikely.) It’s worth noting that the comprehensive health care reform undertaken by a major state with a much more liberal electorate and collection of legislators took a simialr form as well.

And while nobody can prove the counterfactual, I also agree that President Clinton would have signed something virtually identical to the ACA. It’s true that in a context in which every single one of the maximum number of votes in the Senate available in a very narrow window was necessary, there’s far more risk of a catastrophic downside (health care reform fails outright or settles for token tinkering, either ruining health care reform for at least another generation and squandering a rare historical opportunity) than of a marginal upside (it’s highly unlikely that everything Obama did was optimal, but nobody has articulated a scenario in which every single conservative Democratic senator votes for a singificantly more progressive bill). But nobody learned the lesson of failure of the Clinton administration’s health care reform more vividly than Hillary Clinton; she was if anything even less likely to going try the “develop a plan and shove it right down Congress’s throat with the ram of the BULLY PULPIT!” strategy beloved by people who have no idea what they’re talking about again. And moreover, she had in the interim actually served more than one term in the Senate; she certainly wasn’t going to listen to asinine amateur-hour advice about how she should sit down with Max Baucus and Joe Lieberman and tell them to cut the bullshit. It’s overwhelmingly likely that something virtually identical to the ACA would have passed with Clinton in the White House. With Edwards, it’s trickier, but he was never going to be the Democratic nominee for a variety of reasons.

Finally, the fact that Obama’s pandering on the mandate was abandoned when it was time for actual presidenting also further reveals the stupidity of the “but the ACA and Romneycare the plan passed by massive supermajorities of Masschusetts Democrats over Mitt Romney’s many vetoes were just a slightly varnished Republican Heritage Foundation plan” line of argument. The only important thing that the Heritage Foundation’s never-serious plan to force every non-healthy adult to pay for unregulated catastrophic insurance while destroying Medicare and Medicaid has in common with the ACA and MA health care reform is the mandate. But the mandate is just an obvious requirement of any program that has guaranteed issue — that is, any serious health care reform that doesn’t perform the politically impossible task of eliminating the American insurance industry. Barring a level of subsidies that wasn’t forthcoming from Congress, guaranteed issue can’t work without a mandate — the alternatives, like Paul Starr’s proposal that adults who forgo insurance sign contracts to refuse emergency care health care benefits* for a given time period, were both politically impossible and, in my view, substantially worse on the merits than the mandate. The free rider problem is not, in fact, some unique insight on the part of Heritage Foundation hacks. Any comprehensive health care reform was going to take the shape of guaranteed issue with mandate, and other than that the ACA and the Heritage Foundation plan couldn’t be more different.

*UPDATE: As a commenter notes, Starr’s proposal would not have applied to emergency care, but only to any benefits of the law (including, presumably, COBRA or Medicaid.) I’ve corrected to reflect my error. I stand by my criticism of the plan as both politically unworkable and inferior to the mandate; refusing access to the market for people who lose employer-based coverage would be still be horrible, and if it didn’t apply to emergency care it would also deal much less effectively with the free rider problem. See also Cohn’s contemporaneous response.

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  • NonyNony

    …like Paul Starr’s proposal that adults who forgo insurance sign contracts to refuse emergency care for a given time period…

    Wait, whut?

    Can someone please assure me that this was a “proposal” in the sense of “a modest proposal” and not something that someone seriously offered up as a good idea. Please? Because if I’ve got the right Paul Starr he’s not some glibertarian whack-job but a Democratic policy adviser and that is just sixteen levels of screwed up.

    • Peter H

      See Starr’s article in the New Republic:

      My preferred alternative has two parts-one to make the law more forgiving, the other to make it more tough-minded. First, the government would allow individuals to opt out of the new insurance system without any penalty; people would do so by signing a form on their tax return acknowledging that they would be ineligible for benefits under the law for a fixed period—say, five years. Second, the government would raise the annual penalties for neither buying insurance nor taking the opt-out.

      I think Jonathan Cohn had a good response to Starr.

      • NonyNony

        Starr’s not suggesting that in that article. He suggests this:

        What if someone took the five-year opt-out and later reconsidered? … In other words, they would face a market much like the one that existed before the law. I would not advise anyone to opt out. But, if they did, they would be no worse off than they are now.

        In that article at least what he’s saying is that if you opt-out, you have opted-out of government protection from scam artists and you’ve opted-out of the subsidies. You’re on your own and at the mercies of whatever predator companies come along that want to eat you alive.

        While this is just an awful, awful idea that could only have been come up with by someone with vast amounts of personal privilege, it isn’t nearly as bad as “opt out and you opt out of emergency care”, which would effectively be a choice worse that what we have now. His case seems to be that somehow, people who opt out of the ACA would have a market the same as the one that existed pre-ACA if they realize that they made a dumb move and want to get insurance after they opt out.

        (Except, of course, that wouldn’t be true – the risk pools for people like that would be quite different from the risk pools that existed pre-ACA because quite a number of the healthy but cautious people would have chosen to purchase insurance off the exchanges. Leaving only a collection of short-sighted relatively healthy people who engage in risky behavior (like not purchasing insurance) who suddenly decide that they need insurance. This group is not likely to be treated well by the actuaries at any company…)

      • Scott Lemieux

        Thanks very much for this. I should have checked before I made the assertion.

  • Ronan

    But doesnt this back up G-Vitchs initial point, that the problem is internal to the Dems and can only be changed by switching from a belief in technocratic solutions within the party, to a concentration on ‘mass politics’?
    Secondly, doesnt it also imply(which is something jfl pointed out in a previous thread) that the running for healthcare reform came from within the party (not the president) so that an alternative, realistic Dem president (Hillary maybe) would have also pushed for healthare reform? Or was this something so specific to the Obama admin that a Hillary admin wouldnt have pushed the policy?

    • Ronan

      sorry for second question, dont know how i misssed that that was answered in OP

    • Pat

      It’s not a problem, Ronan, it’s reality. The ACA was the sum total of what was politically possible.

      • Ronan

        But his point is that it doesnt have to be a reality if the Dems were internally willing to change politial priorities (in the l/t)

      • Ed

        It’s not a problem, Ronan, it’s reality. The ACA was the sum total of what was politically possible.

        We’ll never know. Max Baucus admitted that taking single-payer off the table was a mistake, handing the opposition a nice concession for nothing and leaving the public option out there to be attacked as the crazy-lefty position. That wasn’t the only unforced error.

        • Scott Lemieux

          Yes, clearly if Max Baucus made a ridiculous assertion it must be true. Joe Lieberman would have totally voted for the public option had only someone made what everyone knew to be a completely empty threat to pass single payer.

    • I think the key failure here is in thinking, as Scott says, that this had to pass or there would be no opportunity for another generation. That’s not an analysis of the actual costs and benefits of the bill as compared to any incremental approach. It’s just a pure reaction to the frustration of not passing something in the past.

      I think that explains why Scott forgot the actual reason for national health insurance (because people should not have to pay for their medical care, which is a result of accidents of life and bad luck and should be a societal obligation), in favor of second order concerns like making insurance slightly more generous and covering a segment of the individual market that had preexisting conditions.

      The reasoning was backwards- we must pass some type of comprehensive bill because this is our only window, therefore whatever we pass must be defended.

      • Ronan

        I see what youre saying, but can understand why people mightent be willing to wait another generation (and might be sceptical it could work then)
        I guess, if it were my country, id go for this now,than something possibly better in the future

      • junker

        Your willingness to write off the needs of those with pre-existing conditions is heartwarming.

        • joe from Lowell

          The difference between having health insurance and not having insurance is “slight,” according to Dilan.

          No doubt, his long years raising a family without having health insurance informed his opinion on this matter.

          • Scott Lemieux

            The difference between having health insurance and not having insurance is “slight,” according to Dilan.

            Although I suppose this helps to explain why Dilan and those with similar views consider the ACA a mere minor “variation” of the Heritage Plan. Anything other than universal access to the best employer coverage available is equally shitty!

            • joe from Lowell

              It’s sort of like his foreign policy. He doesn’t care about whether or not people overseas are killed, or dominated by a foreign power. He only cares that the US government is not involved.

              Similarly, he doesn’t care about whether people in the US have health care coverage; he only cares about making sure the insurance companies aren’t involved.

              • I really don’t care, as a first order matter, if insurance companies are involved. I don’t trust them and think that one way Obamacare may unravel is through its reliance on for profit insurers, but to put it clearly, a health care plan that used government money to buy a “cadillac” plan from private insurers for every American is one I would clearly support.

            • Anything other than universal access to the best employer coverage available is equally shitty!

              Not equally. But what I care about in the end is how close to free it gets. The Bronze plans I looked at look like they hit anyone who needs regular doctor visits or prescriptions with thousands of dollars of bills every year, plus the premium. That’s not very good.

              • Scott Lemieux

                Except that the relevant baseline is not “Cadillac employer plans” but “nothing.” Your standard is just irrelevant — I mean, I have a better-than-bronze health care plan and I pay co-pays for nearly everything.

                • Part of my problem here is I don’t know if a person who goes bankrupt and doesn’t pay his or her medical bills under the current system is really any worse off than a person who gets just enough insurance that he or she can spend all his or her disposable income and savings on medical bills under a bronze plan would be.

                  It’s a question that will be answered in time, with data. Not by condemning anyone who is skeptical about Obamacare with snarky arguments.

        • I’m not writing them off. I’m saying that isn’t the reason there was a health insurance crisis.

          There was a health insurance crisis because we relied on a market which priced people out of purchasing things that should be provided by society (because medical problems are a result of losing life’s lottery). And, to be blunt about it, it was mostly poor and working class people who faced this.

          The middle class self-employed people who could not buy individual insurance because of a pre-existing condition were a public policy issue, but they weren’t the health insurance crisis. The difference is, if you redefine the problem that way, it becomes easier to “solve”.

          • Manny Kant

            Surely the ACA contains a lot of good things for the poor and working class people who didn’t have insurance: a vast expansion of Medicaid for the poor and substantial subsidies to enable the working class to purchase insurance. Also, practices like bans on pre-existing conditions and rescission surely affect the working class and poor just as much as anybody else.

            • One of the reasons I am waiting and seeing (and I AM waiting and seeing) is because of that. It’s possible Obamacare will improve things. I certainly opposed all the Republican attempts to sabotage it. It should be given a chance to work.

              I am just skeptical (Medicaid isn’t the world’s best public insurance program, by far) and certainly don’t buy any attempt to declare it a success by redefining the problem.

          • mpowell

            I think you are just badly wrong about what the crisis was. The pre-existing conditions pool is exactly the pool of people who were being priced out of medical care that society should be providing them. For people with ongoing prescriptions and treatment, the ACA brings their annual medical expenses down from the $30K+ range down into the <$10K range. That is a big deal! This isn't care that occurs one time that you can get and then file for bankruptcy on. This isn't stuff that the hospital has to give you. It's medications that prevents your condition from getting worse so that you don't have to go the emergency room and have an operation that substantially shortens your lifespan and/or limits your range of action. So this is a life or death issue for middle class Americans with these kinds of conditions. The subsidies offered by the ACA allow everyone, even someone who is quite poor, choose life. They may have significantly less spending money than they otherwise would, but the pre-ACA alternative is not simply a medical bankruptcy. It's not getting the treatment that you need and dying substantially earlier as a result.

            The other class of issues the ACA deals with is bringing down the cost of preventive health care for those who don't get healthcare at work and can't afford it otherwise. And the ACA addresses that as well, though it isn't free. But there is a big difference between, "well, this is a substantial expense in our budget" and "I have no way of obtaining this care and am going to die as a result". And that's the kind of difference we are talking about.

      • Scott Lemieux

        I think the key failure here is in thinking, as Scott says, that this had to pass or there would be no opportunity for another generation.

        How often do Democrats have 60 seats in the Senate? Because that’s one minimum requirement. (I also love that there’s a 100% overlap between people who believe that Senate Republicans would agree to a better plan than the ACA in the near future and people who believe that Obama fucked up because of an excessive belief in bipartisanship.)

        I think that explains why Scott forgot the actual reason for national health insurance (because people should not have to pay for their medical care, which is a result of accidents of life and bad luck and should be a societal obligation)

        Just to be clear, are you arguing that it would be possible — in the near future, yet — to guarantee every American a standard of care even most good employer plans don’t provide while eliminating the private insurance industry? Do you know anything at all about American government? (I note again, as well, your willful inability to distinguish between normative and empirical arguments.)

        in favor of second order concerns like making insurance slightly more generous and covering a segment of the individual market that had preexisting conditions.

        This, I guess is our fundamental disagreement. You believe that “I’ve got mine, fuck you” is a fundamental progressive principle, I don’t. Relatedly, you agree with the Republicans that under any set of political circumstances possible in our lifetime the optimal health care reform policy is “nothing” (at least for adults between 18-55), and again I disagree.

        • I also love that there’s a 100% overlap between people who believe that Senate Republicans would agree to a better plan than the ACA in the near future and people who believe that Obama fucked up because of an excessive belief in bipartisanship.

          Not so fast there, Scott – I believe that Obama’s being too ready to compromise is a flaw because the Republicans are so intransigent in their opposition to him.

        • Just to be clear, are you arguing that it would be possible — in the near future, yet — to guarantee every American a standard of care even most good employer plans don’t provide while eliminating the private insurance industry? Do you know anything at all about American government? (I note again, as well, your willful inability to distinguish between normative and empirical arguments.)

          No, I am saying that this is the actual problem. And the ACA should be judged on how far it gets us to solving THAT problem, not whether it prevents a bankruptcy here or there or allows a few people who have preexisting conditions to purchase a plan that still carries high out of pocket costs.

          • sibusisodan

            not whether it prevents a bankruptcy here or there or allows a few people who have preexisting conditions

            Did you thoughtfully choose those words? If so, may I direct you to a source of internet wisdom, who saith:

            most internet commenters are actually not very good at constructing coherent arguments and thinking deeply about issues as opposed to just reacting.

            • You want me to be more specific, I will be (unlike assholes who use snark).

              The individual market is a small percentage of the health care market. Most coverage is employer based. So the preexisting condition problem is real, but it is not gigantic as compared to the people who have to pay for health care they can’t afford problem.

              And medical bankruptcies, while bad, are a secondary problem and a symptom. If you go bankrupt, after all, you get a discharge. It’s not great, but you don’t have to pay the bills either. Policies that give people just enough support to avoid bankruptcy but sap all their savings and disposable incomes are arguably no improvement at all over bankruptcies.

              As I said, these are problems, I am not minimizing them. But they are not the main problem. And I am interested in how well Obamacare solves the actual problem that health care should be free because it is unfair for people to bear prohibitive costs because they lose life’s lottery.

              • sibusisodan

                You want me to be more specific

                It’s not your specifity that I have a problem with. It’s your accuracy and your self-awareness.

                As I said, these are problems, I am not minimizing them.

                Yes you are. A bankruptcy here and there? A few people with pre-ex?

                Those are your words. Fairly snarky too, if you’ll allow me the liberty of saying so.

                Those two issues are real extensive problems, which I really hope the legislation will mitigate.

                Nobody, but nobody, is claiming that they are the sum total of all us healthcare issues, or that it’s an ideal solution.

                Treating the medically bankrupt and the uninsured with disdain because the legislation which provides for them doesn’t go far enough for you?

                That doesn’t make sense to me.

                • I explained it above– over 40 million people in America have no health insurance. Most of that is not due to the preexisting condition issue, and we have to wait and see whether a bronze plan is an improvement in their lives versus a medical bankruptcy.

                  But that’s the category 5 hurricane here. The fact that there are some other category 2 storms in the health care system (which there are) does not mean we should shift focus.

                • joe from Lowell

                  Dilan seems to think that those people without health insurance get the care they need, and merely suffer economic hardship.

                  Because they can go to the emergency room?

          • junker

            Honest to God, do you listen to how completely sociopathic you sound? Your literal argument is that the millions of people who would be worse off under the status quo should deal with it because the ACA isn’t a “pure” enough solution in that it doesn’t get rid of all insurance agencies.

            And what’s funny is that the people you purport to care about (the very poorest) are the ones who will be most helped by the deal, in the form of expanded access Medicaid.

            • I am willing to wait and see. I am skeptical about Medicaid because it is such a shitty program. But if it actually works, good. (Or maybe we can repeal the rest of Obamacare in exchange for a further Medicaid expansion, I don’t know.)

              But as I said, we have a system where millions of Americans are forced to basically spend all their money on health care or just get sick because they lost life’s lottery. That’s the crisis. The preexisting condition issue is AN issue. I am not minimizing it. But it isn’t the health care crisis, which is a couple of orders of magnitude larger.

          • Scott Lemieux

            No, I am saying that this is the actual problem.

            No, it isn’t. The problem is people who don’t have access to health care, and there’s the additional problem of people who will be bankrupted if they get into an accident or contract a disease. You can’t just define lack of access to the best employer plans as the only “problem,” and the baseline this arbitrary definition creates makes it irrelevant to judging any policy that could actually be enacted by Congress.

            Medicaid because it is such a shitty program.

            Compared to what?

            • The problem is people who don’t have access to health care, and there’s the additional problem of people who will be bankrupted if they get into an accident or contract a disease.

              The problem is, indeed, people who don’t have access to health care. What remains to be seen is whether a bronze plan gives them sufficiently more access than simply getting charity care and going bankrupt did to improve their lives. That question isn’t answered yet and can’t be answered yet no matter how many pixels you waste arguing how great Obamacare is.

              Compared to what?

              Charity care? Defaulting and going through a medical bankruptcy.

              Again, we will see how Medicaid expansion works. It may improve people’s lives, but that’s going to be an empirical question. The one experience I had dealing with Medicaid beneficiaries in my life was not one that convinced me it was a very good program, and that was in a state (California) that had comparatively generous benefits. (Basically, only a few hospitals in LA took MediCal patients, along with some clinics, and people waited more than 24 hours in the Orthopedic Hospital while all the people with insurance were treated first.)

              • IM

                Charity care?

                Are there no prisons? Are there no workhouses?

                I am more and more thinking you are the first person here attacking ACA from the right.

              • sibusisodan

                That question isn’t answered yet and can’t be answered

                I’m sure you could make a decent stab at it by comparing the health outcomes of those without insurance to those with bronze-level insurance equivalents in the pre-Obamacare market.

                Care to take a bet on what that would show?

          • Hogan

            You know who disagrees with Dilan? Elizabeth Warren.

            You know who agrees with Dilan? Megan McArdle.

            • N__B

              I believe the technical term for comparing someone’s argument to McArdle’s is ad moroninum.

      • Joe

        because people should not have to pay for their medical care, which is a result of accidents of life and bad luck and should be a societal obligation

        “A societal obligation” is spread out, including the cost, over society. So, people will have to pay in some way. If there is a single payer, e.g., people will have to pay for it somehow. ACA uses the insurance companies more here (though a large segment still get government based insurance) than some like, but the bottom line holds.

        insurance slightly more generous and covering a segment of the individual market that had preexisting conditions.

        I think the bottom line was that people need health insurance and the status quo ante was that some just couldn’t obtain it or at best it was too much of a burden. Not paying for health care individually was not for me the the goal, so I guess there is a difference of opinion.

        This continual minimalization (“slightly more”) is also tiresome. It’s amazing we even CARE about ACA how minimal it all is that hundreds of thousands of more people already have health insurance that did not have it. Also, the summary doesn’t even actually deal with the whole nature of the law unless “generous” entails addressing the part where costs as a whole will be drawn down, which is a major part of the whole affair.

        Also, as with the New Deal, the law put the feds foot in the door. Republicans already are starting to admit that it has good things for people. After non-action from Obama was even born, there has been a significant change. Finally, yes, given how hard this took even with sixty votes in the Senate and a Democratic President, after generations of failure, why SHOULDN’T we fear inaction would have led to years of more failure? That’s what history showed us.

        • junker

          This is the part that always cracks me up. Even a perfect world single payer system isn’t free! At some point, everyone pays into the system, whether by their tax income or, in the case of the ACA, via private insurance.

          If your critique is that the ACA costs more, fine, say that. But Dilan’s notion that public health care is “free” and the ACA is not is intentionally misleading.

          • Lee Rudolph

            But Dilan’s notion that public health care is “free” and the ACA is not is intentionally misleading.

            Don’t be silly. It’s quite clear that in this case “free” means (and Dilan intends it to mean) that the cost to any given consumer of providing the particular good in question (in this case, health care) is independent of that consumer’s use of the good. (Other details, which go to “how free?”, are less clear.)

            • Correct. In Britain, you go to the NHS clinic and you are not charged. Obviously, British citizens pay for this extremely popular service. But the people who are unlucky enough to need it don’t have to pay for it.

              I want to see how far along Obamacare gets us to THAT sort of system.

        • “A societal obligation” is spread out, including the cost, over society. So, people will have to pay in some way.

          The point is to have the healthy pay the costs of treating the sick.

          I think the bottom line was that people need health insurance and the status quo ante was that some just couldn’t obtain it or at best it was too much of a burden. Not paying for health care individually was not for me the the goal, so I guess there is a difference of opinion.

          I think it is right that there is a difference of opinion. But that’s why Scott’s argument is so wrongheaded. He has redefined the problem such that Obamacare is the solution. But many people think the health care crisis is something other than he says it is. Now, his response to that is to say “nothing that solves the crisis you are talking about could pass”. I suspect that is true if you are talking about comprehensive solutions, and may not be true when you are talking about incremental solutions.

          But the point is, and he’s never gotten this in any of his debates with those to the left of him, there really are ideological differences between liberals and the left. Leftism isn’t just liberalism that wants magic ponies from the political system– it’s a critique of liberalism. And part of the critique is exactly this– that problems get redefined in terms of how they affect middle class constituents of liberal politicians, so that solutions that are friendly to the interests of corporate donors are the only ones on the table.

          It isn’t just “hey we all want single payer but you don’t understand it can’t pass”. I actually don’t want single payer; I want a national health service. I think for-profit hospitals are just as bad as for-profit insurance companies. But that’s not the main point– the reality is it is more like “hey, you think the problem is a few people can’t buy individual insurance because of pre-existing conditions, and we think the problem is that a whole lot of people are being forced to pay huge amounts of money they don’t have on medical care that should be society’s obligation because it is dependent on luck”. That doesn’t mean I magically have the votes for single payer or NHS. It does mean that when judging Obamacare, I don’t think medical bankruptcies or preexisting conditions are the metric; it’s how many people no longer have to pay for their medical costs.

          • Scott Lemieux

            debates with those to the left of him

            Assumes facts that are clearly false.

            Again, the fact that if you were Prime Minister of the United States you’d create an NHS doesn’t make you to my “left.” And what you’re actually offering to uninsured adults between 18-55 under any foreseeable political context — “fuck you, I’ve got mine” — is just flat-out reactionary. I know you’d prefer to flatter yourself, but not understanding how American politics works isn’t a metric of progressiveness.

            affect middle class constituents

            Wow. The expansion of Medicaid affects “middle-class constituents?” The fact that you not only don’t see the working poor lacking access to medical care as a problem but want to cloak your indifference in a mantle of leftist purity is just jaw-dropping. I’ll also note, again, that your analysis of American political institutions is, in fact, 100% pure complacent middlebrow liberalism; there isn’t a trace of leftist structural critique to be found anywhere.

            • And what you’re actually offering to uninsured adults between 18-55 under any foreseeable political context — “fuck you, I’ve got mine”

              This is precisely the opposite argument to the one you make on Roosevelt and Social Security, where you DEFEND FDR against any suggestion that the discrimination against blacks in the New Deal for incremental reasons was “fuck you I’ve got mine”.

              I’m beginning to think you have no principles whatsoever other than a desire to mount a hackish attack of anyone who even asserts they are too your left.

              • Scott Lemieux

                Holy non-sequitur! To state the obvious, my arguments in both cases are identical. The New Deal, despite its obvious moral and policy compromises, was a clear improvement of the status quo. The ACA, despite its policy compromises, was a clear improvement over the status quo. Both are worth supporting for the same reasons.

                You, on the other hand, are logically committed to the proposition that none of the New Deal should have been passed until the votes of southern Democrats were no longer needed. But you totally Speak For the Left!

            • Hogan

              Per Dilan, there are no working poor; if you’re working, you’re middle class.

              • junker

                As he said down thread – repeal the Bush tax cuts, because it won’t affect the unemployed. Who cares about the working poor?

      • The Sheriff’s A Ni-

        in favor of second order concerns like making insurance slightly more generous and covering a segment of the individual market that had preexisting conditions.

        “A single person suffering from pre-existing conditions is a tragedy, a million suffering from pre-existing conditions is a statistic.”

      • joe from Lowell

        That’s not an analysis of the actual costs and benefits of the bill as compared to any incremental approach. It’s just a pure reaction to the frustration of not passing something in the past.

        No, it’s not. It’s an accurate description of the history of failed health care reform efforts.

        • The history of failed health care reform efforts is not proof that Obamacare is a good bill or an improvement.

          • Malaclypse

            Then you need to rationally explain why the status quo was better than the ACA.

            • It depends on what other reforms were possible within the status quo. Which we really can’t know, but the best evidence is that S-CHIP expansions passed, which means there was probably some constituency for improving government health care.

              • Scott Lemieux

                This, of course, is non-responsive to the question of whether the ACA improved the status quo, and in addition arbitrarily re-defines many actual longstanding concerns of progressives as non-problems.

                • Scott, I didn’t know you spoke for all liberals and leftists (don’t use that stupid spin word “progressive”) as to what they believe.

                  Some of us disagree with your priorities. That’s the point– you will never acknowledge that, because you’d rather think the DFH’s are naive and don’t know what is good for them.

                • Scott Lemieux

                  Some of us disagree with your priorities. That’s the point– you will never acknowledge that, because you’d rather think the DFH’s are naive and don’t know what is good for them.

                  Right — mine are progressive, yours are reactionary.

              • MAJeff

                Then you need to rationally explain why the status quo was better than the ACA.

                It depends on what other reforms were possible within the status quo.

                Talk about a goalpost shift.

                • Steve LaBonne

                  Them there goalposts are on wheels and motorized.

                • Really? Anyone who opposes Obamacare not only favors the status quo, but can’t even ARGUE that something else, no matter how modest, could pass?

                  That’s completely idiotic.

                • sibusisodan

                  can’t even ARGUE that something else, no matter how modest, could pass?

                  Go on then. Argue it. Tell us what you think could have passed and what effect it might have.

                  How do you expect us to understand your position – or even come to share it – if you won’t explain it?

                • Malaclypse

                  You said the ACA was not an improvement. I assumed you meant “not an improvement over the status quo.” If that is not in fact what you meant, but that you meant that it was not an improvement over imaginary policy not being proposed by any actual legislator, then well, yes, the ACA is not an improvement over the “Dilan’s Act To Make Everything Perfect Forever, Plus Ponies And Warm Apple Pie A La Mode.”

                • I mean “not an improvement over something else that Obama could have proposed and passed”. And I have suggested that while we don’t know for certain, we have evidence in the form of S-CHIP expansions (and health insurance portability, I might have added) that incremental health bills can pass.

                  I am not claiming I know for sure that there’s this specific other bill that would have been better than Obamacare. I’m arguing that Obamabots in this thread are using this argument to shut off debate on an issue where they are talking out of their asses, when they really have no idea what else could have passed or how it would compare (especially since we don’t have any outcomes on Obamacare yet).

                • junker

                  The thing is, we have the reality of what actually happened. it is incumbent on you to describe exactly what evidence you have to suggest that something better (or the same quality implemented differently) could have happened, and how that could lead to a better outcome down the line than the ACA.

                  I mean, I could propose that Obama could have assumed dictatorial control of the country and made selling health insurance illegal as something that “Might have happened under Obama.” Notice that I can’t provide any evidence of this.

                  You keep saying that ACA supporters are shutting off debate and that we have no idea how things could have turned out. Well tell us – how could it have turned out? How could it have been better? What proof do you have of this? Because otherwise you’re just aimlessly speculating.

    • Scott Lemieux

      But doesnt this back up G-Vitchs initial point, that the problem is internal to the Dems and can only be changed by switching from a belief in technocratic solutions within the party, to a concentration on ‘mass politics’?

      Well, no, because he implies that it was possible to enact single payer in 2009 but it didn’t happen because of Obama’s unfettered and unconstrained personal preferences.

      • Ronan

        Its not though because he placed the problem in the way the Dem elite approach politics, not *only* in Obama’s personal preferences.
        Im not sure its here nor there though really, in the context of this post

        • Scott Lemieux

          Its not though because he placed the problem in the way the Dem elite approach politics, not *only* in Obama’s personal preferences.

          Well, OK, but his characterization is just wrong. The unprecedented passage of major social reform on a party-line vote make it pretty clear that his assertion that Democratic elites are averse to partisan conflict is nonsense.

          • mark f

            Also he’s skipping over another point you made in the post. How did Barack Obama catch fire as a primary candidate in the first place? The same way Howard Dean did in 2004: he was, contra his Dem elite opponents, opposed to the Iraq War. But there was never a similar demand for a candidate advocating single-payer, indicating that mass politics is not such an obvious solution.

      • rea

        And, fuck, putting together something necessarily as complicated as a program for univeral health care must be addressed technocratically, and not simply by mass politics; otherwise you have a big, popular program that doesn’t work.

        • LeeEsq

          Like I said in previous posts, implementing single-payer or Dilan’s National Insurance would require some very radical changes that would be even harder to implement than the ACA.

          Nye Bevan, working in conditions that were much more favorable to radical change than Obama, still almost had NHS destroyed by what amounted to the vested interests.

  • Cranky Observer

    Surveys over the last 10 years have consistently shown that 85% of Americans – all Americans, not just Democrats – want Social Security benefits maintained or strengthened, yet all big-name candidates eventually “converge” on the Peterson-Bowles formulation of crisis+chopping. Which leads one to believe there are other factors driving this magical convergence than just median voter calculation.

    • JKTHs

      yet all big-name candidates eventually “converge” on the Peterson-Bowles formulation of crisis+chopping

      Yeah, it explains all those Social Security cuts that have been enacted in the past couple years.

      • JKTHs:
        So why does the president’s CoS keep saying they’re open to it in the TradMed? You know damn well that they’d do it but are only saved because Grover won’t let the GOP off the leash even for 5 minutes.

        • junker

          So explain this to me: if this is such a big priority for Obama and the dems, why didn’t he push it when they had unified control of government in 2009/10? Afterall, they could have done anything they wanted then, and if they’re so desperate to cut these programs they easily could have. Why didn’t they?

        • Scott Lemieux

          Which leads one to believe there are other factors driving this magical convergence than just median voter calculation.

          Well, of course. And there are some on the left who when arguing about the ACA ignore the extent to which the American institutional playing field is tilted towards monied interests. But I’m not one of them.

          So why does the president’s CoS keep saying they’re open to it in the TradMed? You know damn well that they’d do it but are only saved because Grover won’t let the GOP off the leash even for 5 minutes

          Except, of course, that if this was a policy Obama actually wanted (as opposed to something he’s willing to live with if he can obtain other goals), he wouldn’t tie the proposal to conditions he knows Republicans wouldn’t accept.

        • joe from Lowell

          So why does the president’s CoS keep saying they’re open to it in the TradMed?

          You know the answer to this. Can we skip the preliminaries please?

    • TT

      The press (both reporters and most pundits) and other Democratic candidates, to say nothing of the GOP/Fox News complex, would have absolutely savaged anyone who campaigned on single-payer in ’08, making it politically toxic and thus abandoned within about 30 seconds. Maybe the terrain will change in the coming years but it’s hard to see how.

      • This.

        Obama was castigated for months for daring to suggest we so much as talk to Iran. If he (or Edwards) had proposed Medicare for all or something, he would’ve been dumped into the Kucinich loony bin of unSerious liberal dreamers. Maybe that wouldn’t have mattered in Iowa, but maybe it would have.

      • The press (both reporters and most pundits) and other Democratic candidates, to say nothing of the GOP/Fox News complex, would have absolutely savaged anyone who campaigned on single-payer in ’08, ..

        Proof? Medicare is pretty damn popular. So why not Medicare-for-all? All the scare mongering by the TradMed hasn’t most the needle on whether people like Social Security or Medicare much at all.

        • I agree with Scott that Medicare for all couldn’t pass yet. Expansion of Medicare, without the rest of Obamacare, might have.

          • David Hunt

            Uhm…I read just yesterday (sorry I can’t remember where) that early in the process Joe Lieberman was offering to lower the Medicare eligibility age to 55 in exchange for dropping most of Healthcare Reform and putting in a few minor fixes. At least he was “offering” this until he found out that there were a bunch of Democratic Senators that were really interested in that deal, at which point he immediately stopped “offering” it. I don’t think there’s any way Mr. Sixtieth Vote would have supported a Medicare expansion.

            • How about if Obamacare had never been proposed and therefore there was no unified Republican opposition?

              • IM

                and therefore there was no unified Republican opposition?

                That presumes the existence of a moderate republican wing. But we are no longer in 1990 anymore.

                Just look at the careers of Chafee and son.

                • Scott Lemieux

                  And, also, even if it were possible the idea that trading a Medicare buy-in for those 55 to 60 for the ACA would be a good deal is insane.

                • Scott, the fact that you think that is insane is a IDEOLOGICAL DIFFERENCE between you and other people on the left.

                  That’s fine. You prefer centrist corporate healthcare to the expansion of single payer systems.

                  About 85 percent of my problem with you on this issue is you won’t admit that you actually disagree with people to the left of you. You just want to call them stupid.

                • Hogan

                  Well no, he prefers covering many more people to covering a few more people. He’s fine with expanding Medicaid.

                • The question is to what extent a bronze plan under Obamacare is more coverage than defaulting and going bankrupt. It remains to be seen.

                • Scott Lemieux

                  That’s fine. You prefer centrist corporate healthcare to the expansion of single payer systems.

                  Your ongoing failure to comprehend the difference between normative and empirical arguments is remarkable. You’re imagining an ideological disagreement that doesn’t exist, except to the extent that you’re arguing for substantially more conservative policies. And, as noted below, the ACA in fact contained an expansion of single-payer much more substantial than a minor Medicare buy-in so your argument fails even on its own stupid terms.

                  disagree with people to the left of you.

                  Like who? Certainly not you.

        • junker

          Are you serious? Did you see how much angst was directed at the Dems for the relatively limited intervention of the ACA? You really think everyone would have rationally thought about “Gubmint getting in my healthcare?”

          • Without Obamacare (a full scale restructuring of US healthcare and an ideological talking point for the right) on the table, who knows what could have happened.

            S-CHIP expansions have repeatedly passed. The idea that there’s no way to expand government health care is false.

            • sibusisodan

              a full scale restructuring of US healthcare and an ideological talking point for the right

              But you want a national health service! Which is both of those things and more. You can’t complain that those are also side-effects of a non-preferred solution without showing how to avoid those effects in getting to your solution.

              The advent of the NHS in Britain was achieved through a generations-long process of partial and inadequate reforms preparing the ground for a radical nationalisation of health services.

              For you to complain about what could be a similar trajectory in the US is both historically illiterate and churlish.

              Unless you can show how ACA forever blocks the route to nationalisation, or deflects from a plausible gradualist approach to the same.

              • I’m not claiming I can pass a National Health Service.

                I am saying I am not convinced by the argument that it was Obamacare or nothing, as opposed to Obamacare versus a more incremental law that would have had better outcomes overall.

                • sibusisodan

                  Then you need to offer some account of how an incremental law comes into being, what it does and who votes for it.

                • IM

                  more incremental law that would have had better outcomes overall.

                  Sure a more incremental law would have been possible, But how could a narrower law have produced better outcomes overall?

                  You entioned medicare beginning at 55. But even if that can still be called incremental it would have left all uninsured under the age 55 out in the old.

                • Sure a more incremental law would have been possible, But how could a narrower law have produced better outcomes overall?

                  You entioned medicare beginning at 55. But even if that can still be called incremental it would have left all uninsured under the age 55 out in the old.

                  It remains to be seen whether Obamacare will actually benefit the lives of those who are supposedly now covered. That’s why we have to wait and see rather than declaring this untested law a smashing success and an improvement over any other conceivable outcome.

                • junker

                  You keep saying “It remains to be seen,” but as Sibusodian says up thread, I imagine you could actually compare the equivalent of bronze level plans in the current market to people without insurance and see how their outcomes compare.

                  I also think that it is really, really heartless that you seem to think that the worst possible outcome for someone under the older system with poor or no insurance is bankruptcy. Leaving aside how awful bankruptcy is, this is a literal matter of life or death for many, and the fact that you feel the need to minimize that doesn’t bode well for your argument.

            • bluemeanies

              S-CHIP expansion and Medicare buy-in at 55+ (which was never subsidized just a guaranteed issue public option), seems to me that your approach is completely ‘children and seniors first’, which is a piecemeal framework that does not do much for the large part of the population between 18-55 where much of the problem is located. Granted, previous piecemeal didn’t include the 55-65 but that was a tough sell that had already discussed political obstacles. For this approach to actually work you have to believe that the people pursueing this strategy will ever do anything for the bulk of the adult population, people whose needs have repeatedly been put on the backburner of health policy because a ‘seniors and children first’ program has been the standard of possible for a long time.

        • joe from Lowell

          Proof? Medicare is pretty damn popular. So why not Medicare-for-all?

          Watching those idiots with the “Keep the government’s hands off my Medicare” signs win the 2010 elections didn’t convince you that support for existing social programs doesn’t translate into support for expanding them?

          How about the famous Republican attack line, “They want to cut Medicare to pay for Obamacare?”

    • junker

      Can you provide any evidence of any politician campaigning on SS cuts and reform?

      Or rather, how many winning politicians have made that pitch during their campaign?

      • Hogan

        He did say “eventually.” He might be right; we just won’t know until the end of time.

        • I don’t know about you, but I’m praying for the end of time to hurry up and arrive. If I have to spend another minute on this issue, I don’t think that I can really survive.

          • junker

            God only knows what I could do right now… if I weren’t commenting on a blog :)

          • Chocolate Covered Cotton

            You can see a National Health Service by the dashboard light?

      • TribalistMeathead

        It was a major part of Paul Ryan’s Very Serious Budget Proposal and, while it went nowhere, it did earn him a VP nomination and a personal audience with the President. Not bad for a junior Congressman from Wisconsin.

        • junker

          ??? I guess I missed the part where Romney/Ryan won the 2012 election?

          • junker

            As an addendum, Bernstein’s point is that politicians in primaries are responding to their base, and that the fact that all three candidates honed in on the same plan in 2007/08 is evidence that the ACA was considered perfectly fine by mainstream Dems.

            Notice that there wasn’t a similar process about safety net cuts in the Republican primaries of 2011/12, and that for all Ryan is seen as a Grannie-Starver by those of us on the web, that he constantly has to hide the true nature of his plan. Remember the “End of Medicare as we know it” debacle?

          • TribalistMeathead

            Well, there’s the part where Ryan won re-election to the House in 2012…

            • junker

              I guess you missed the second part? About how even Ryan needs to couch his ideas to obfuscate what they mean? About how it’s more okay to say these things in safe seats?

        • JKTHs

          Ryan’s budget has a lot of terrible things, but it doesn’t do anything on SS.

      • That’s the problem. They never campaign on something as toxic as that. Yet, Obama’s people(his CoS) always go around to the TradMed talking about Chained-CPI.

    • joe from Lowell

      yet all big-name candidates eventually “converge” on the Peterson-Bowles formulation of crisis+chopping

      That must be why it’s never happened.

    • UserGoogol

      I think as a general principle the quasi-centrists who want things like Social Security privatization have way more bark than bite. They represent a small niche which has enough representation in Washington DC and in the national media that they make a lot of noise and they get pandered to, and since they’re quasi-centrist they often get confused for actual swing voters, but really they don’t have much power. If they were as powerful as people imply, Michael Bloomberg would be president.

  • Rarely Posts

    And while nobody can prove the counterfactual, I also agree that President Clinton would have signed something virtually identical to the ACA. . . . It’s overwhelmingly likely that something virtually identical to the ACA would have passed with Clinton in the White House.

    I agree with most of your post, and I agree that the ACA is probably the best deal that Obama could get. But, I’m not sure that I agree with this point. I certainly agree that a hypothetical President Clinton would have signed the ACA if it made it to her desk, but I’m not certain the ACA would have managed to pass Congress with a President Clinton. Most importantly, Obama’s coat-tails were pretty amazing and managed to get the Democrats a lot of house seats and Senate seats that they otherwise likely would have lost. I’m not at all confident that Clinton’s coat-tails would have been that big. Obama’s an amazing and savvy politician, he and his campaign organization managed to galvanize minority and young voters to an unprecedented extent, and he didn’t have a lot of the Clinton baggage. So, I think you’re probably not giving Obama enough credit when you suggest that it’s “overwhelmingly likely” something similar would have passed with Clinton. I personally suspect we would have gotten something much less significant, or nothing at all.

    • Scott Lemieux

      Yes, the only way the ACA is worse under Clinton is if she wouldn’t have had 60 senators. I doubt it, but I’m certainly open to evidence otherwise. Given the same Senate, I think she ends up signing the same bill.

      • Manta

        Given the same senate, but a McCain president, what kind of bill you think would have gotten out?
        Nothing? More-or-less the same?

        • Scott Lemieux

          what kind of bill you think would have gotten out?

          Nothing. That wasn’t going to happen without major agenda-setting on the part of the president.

    • sibusisodan

      It wasn’t until I read your comment that I realised that the President Clinton under discussion was not President Clinton, but President Clinton.

      I hope she runs, and wins, but it will be a bit confusing.

      • UserGoogol

        Although I liked Obama in the 2008 primaries for more substantive reasons too, I have to admit that a big part of me supported him just because I didn’t want the list of Presidents to go “…Bush, Clinton, Bush, Clinton.”

        • Chocolate Covered Cotton

          During the Nevada Caucus, when I saw I was the only one in my precinct supporting Edwards and would therefore have to pick either Clinton or Obama, and I really didn’t know anywhere near as much about Obama as I did Clinton, I picked him over her for precisely that reason. I also remembered the way Repukes had already trashed Clinton for over a decade and figured they wouldn’t be as shameless attacking a black guy. I figured they considered sexist attacks as more acceptable than racist attacks.

          Ah, the naivete of an Edwards supporter…

  • Sly

    Barring a level of subsidies that wasn’t forthcoming from Congress, guaranteed issue can’t work without a mandate

    See New York’s individual market prior to the ACA as an example. When the state implemented guaranteed issue and community rating in 1993, there was a steady exodus from the market (by both the insured and insurance companies) coupled with big, sustained price increases. Despite a few interventions by the state in the subsequent years, the only thing that brought that market some sanity was the ACA; the average bid to participate in the state’s exchange was 50% lower than what was already available.

  • Rarely Posts

    In the last thread, we also had a debate about whether the stimulus was the best Obama could have gotten. After the debate in that thread, I have to concede, I am now mostly convinced that it was (or at least close to it).

    So, here’s a question: For those who don’t think Obama could have done better on the ACA or ARRA, where do we think he made major mistakes in negotiations? Nowhere? He is a great President, but it’s hard to believe that he hasn’t made any significant negotiation mistakes in 5 years.

    I currently think we got a relatively bad substantive deal out of the “fiscal cliff” negotiations. By locking in most of the Bush tax cuts permanently, we made our budget outlook worse and lost a lot of negotiating leverage (as opposed to extending for two years, for example). Moreover, unless I’m misremembering, a lot of the reasoning seemed to be a hope that we could then characterize the Republicans as having voted for a tax “increase” on the highest earners, but I don’t think that panned out.

    My biggest frustration with that is that we didn’t also deal with the debt ceiling at that time — we had something the Republicans wanted (lower taxes) that increased the debt, and it seemed like a great chance to get rid of the debt ceiling. I remember at the time being disappointed with the deal, and now (after all the stupid debt-ceiling battles) it looks like it was a bad one. Of course, maybe I’m being overly optimistic, and maybe we needed all these debt ceiling shenanigans to help “radicalize” the moderate democrats to be willing to eliminate the filibuster (not directly related, but I suspect it’s helped them become more impatient with Republicans).

    Thoughts? Was the “fiscal cliff” deal the best we could get?

    • Brien Jackson

      The sequester was terrible, and not getting a debt ceiling increase out of the agreement to extend the Bush tax cuts temporarily was a huge mistake. As was negotiating over the debt ceiling in the first place.

      • junker

        I’m back and forth about the first debt ceiling debacle. On the one hand, I know Ezra Klein, amongst a few others, was pushing the dems to get a debt ceiling increase during the lame duck session in 2010. On the other hand, it feels like threatening on the debt ceiling was completely new and unprecedented, and so it’s hard for me to say that the Dems ex post ante should have predicted it would be an issue.

      • joe from Lowell

        The sequester only looks “terrible” if you assume that the previous spending levels – that is, those adopted by the overwhelmingly Democratic Congress voted in in 2008 – were available. They were not. After the Republicans won the 2010 elections, budget cuts were going to happen. Elections have consequences.

        Putting those cuts into the form of the sequester delayed them, both kicking the can down the road until a more favorable political environment and moving them further away from the recession.

        As was negotiating over the debt ceiling in the first place.

        A worse idea than handing the economy a default, or the threat of a default, or a government shutdown, in the middle of 2011?

        • junker

          Joe, do you think that the Republicans would have allowed a default? And if so, why have they chosen not to now, later on?

          • joe from Lowell

            I believe the Republicans could have very well bullshitted themselves and blundered into a default. These people engage in magical thinking; remember the predictions about the future of Iraq? They also, using much less magical thinking, have concluded that they can damage the country and Obama will take the political hit.

            They chose not to now because they politics of these standoffs have worked out so poorly for them that they were blinking in 2013 in a way they weren’t in 2011.

          • joe from Lowell

            But even if they didn’t ultimately go all the way to default, just moving in that direction damages the economy.

    • joe from Lowell

      Jacking up middle class taxes in January 2013 would have been a bad idea on the merits. I don’t see that as a real concession.

      • No, it would have been a great idea. The vast majority of the “middle class” taxes we were talking about were paid by rich people, and the people actually out of work and being hurt by the recession were in the working class, not the middle class.

        The whole Clinton focus on the middle class is BS. If you want a welfare state, the middle class has to pay taxes for it, and the poor and working classes are the ones who get the shaft in America; the middle includes a lot of people doing fine.

        • sibusisodan

          Would the effects on the deficit of a large increase in tax intake have been worth the economic costs of a large, sudden increase in the tax intake?

          I say no, and then when you consider the political fallout it just gets worse.

          • Rarely Posts

            The strongest case for extending the tax cuts, which do still favor the wealthy (though less than the Republicans’ preferred alternative), was their stimulative effect in a depressed economy. That’s a strong case, but it doesn’t justify making them permanent and thus taking that bargaining chip “off the table” for the foreseeable future.

            The short-term extension of all the tax cuts in 2010 was worth it because it had a stimulative effect, and it set the stage for repealing DADT, passing the new START treaty, extending unemployment benefits, temporarily cutting the payroll tax, and expanding that earned income tax credits.

            In contrast, it’s hard to argue that the “fiscal cliff” deal was a great deal based on stimulus, in part, because it’s not particularly effective stimulus and because they didn’t keep the tax cuts as leverage. And, the lack of leverage definitely has been a problem in budget negotiations — Democrats can’t threaten to let the tax cuts “expire.”

          • If that’s what you were worried about, we shouldn’t have allowed the Bush tax cuts on rich people to expire either.

            And before you say it, most of the money from the “middle class” tax cuts was also going to rich people (if you believe that taking money from rich people isn’t contractionary), due to the wonders of marginal tax rates.

            • junker

              ???? It’s basic common sense that different types of stimulus are… stimulus. You might say, for example, that a tax cut for people making less than $50,000 is good stimulus but a tax cut for people making $1,000,000 is not.

              Your argument seems to be that supporting one type of stimulus logically means having to support every type of stimilus ever. That is… not very sound.

              • sibusisodan

                Well, I think part of what Dilan will say is that a tax cut for under 50k will also affect the income of those making a million, because of marginal tax bands.

                But, IIRC, the way the poor and rich spend their money is different, with cash aimed at the poorer folk getting you more stimulatory bang for your buck. So I don’t see an issue with being concerned not take not money away from those parts of the economy where it would do most good, even though the rich also benefit from the tax cut extension.

        • joe from Lowell

          No, it would have been a great idea.

          Sorry, D. I’m a Keynesian. Taking money out of people’s pockets in a weak economy is DUM dumb.

          The whole Clinton focus on the middle class is BS. If you want a welfare state, the middle class has to pay taxes for it, and the poor and working classes are the ones who get the shaft in America; the middle includes a lot of people doing fine.

          Dilan thinks the middle class is doing fine.

          Anyway, how about Senator Warren and Senator Sanders’ focus on the middle class? Also BS, or are they the right sort of people?

          • IM

            Of course you are a Kenyan. Like your dear Leader!

            The obot drops his mask.

          • If you think taking money out of people’s pockets in a weak economy is bad, you should have favored extending all the Bush tax cuts, which just like the “middle class” ones, mainly went to rich people.

            As for how the middle class is doing? Yeah, I think the actual middle class (people with incomes and jobs and the rest) shouldn’t be coddled, because invariably, it comes at the expense of the poor.

            Again, remember, if you ACTUALLY didn’t have a job due to the recession, rescinding the Bush tax cuts didn’t cost you anything. The cost was to be borne by the people who still had good jobs, and the better job you had, the more of the cost you paid.

            A “middle class” tax increase doesn’t hit everyone in some theoretical middle class- it hits people who have good jobs and good incomes and doesn’t hit people who don’t.

            • junker

              I wonder how the family of four making a combined $40,000 a year would feel about this. You seem to have a binary view of employment, where you either have a job, and are great, and can bear a greater tax burden, or you don’t. No such thing as the working poor?

            • If you think taking money out of people’s pockets in a weak economy is bad, you should have favored extending all the Bush tax cuts, which just like the “middle class” ones, mainly went to rich people.

              I’m mostly staying out of this…but…did you really mean to say this?

              We know that as income rises, the likelihood of spending a marginal dollar goes down which is why the stimulative effect of cuts to the higher brackets is lower than that in the lower brackets, even though the cuts to the lower brackets benefit rich people as well as poor people. (The “as well as” is key.) Thus, there’s no Keynesian reason to go from cuts in lower brackets to cuts in higher brackets.

              Now getting the comparisons I want (to show where the money is going and propensity to spend) is proving more than I have time for, but there’s this:

              So how many people would actually benefit from preserving the top-tier cuts? Just 1.9 percent of Americans, according to a new report from the nonpartisan Citizens for Tax Justice, which also broke down the impact of the policy on a state-by-state basis. In 22 states, even fewer people, just 1.5 percent — would lose some tax benefits. Under the Republican approach, about 32 percent of the overall tax benefits would go to the top 1 percent of Americans, and nearly half would go to the top 5 percent. Under Obama’s approach, which would preserve the cuts only for families making less than $250,000 a year, those numbers are just 11.4 percent and 30.8 percent, respectively. And despite their talk of deficit control, the Republicans’ plan would cost almost $1 trillion more than Obama’s over 10 years.

              and this (look at point 4).

              • John Maynard Keynes

                Dilan Esper, I’ve been following this thread! You know nothing of my work!

    • Scott Lemieux

      The “grand bargain” offer he made to Boehner — which was apparently sincere, although I haven’t read Scheiber’s book — was really horrible. The House GOP is so awful he got away with it, but the offer was a mistake.

      I should also say that while I’m confident that the ACA was the best possible bill, I wouldn’t say that about the stimulus; I suspect at least a marginal improvement was possible. But the idea that he could have gotten $1.5 trillion by asking for $2 trillion is silly, and there was very good reason to be risk-averse about the initial ask.

      • joe from Lowell

        Obama included a lot of things in the ARRA that were not particularly effective as short-term stimulus, but addressed longstanding Democratic priorities. The alternative energy tax credits and the high speed rail spending (sob!) fall into this category. This decision made the bill less effective as stimulus that it might have otherwise been.

        That’s not really about his negotiating skills, though.

    • Royko

      It’s tough to say, post-2010, because he’s been dealing with a Republican Party that includes a sizable contingent happy to blow up the world. Given that, I’m OK with most of the deals he has struck.

      That said, I don’t think he should have done the first debt limit deal. It was a bad deal for Democrats (worse than for Republicans) and it didn’t prevent Debt Crisis 2. I think he would have been better off waiting until the last minute (I think they would have backed down) and minting the coin, if he had to. But it’s a tough call, especially without hindsight. Dealing with crazies is difficult.

      Pre-2010, I don’t know. I’m fairly sure there was no way of getting stimulus over $1T. He might have been able to squeeze out a little more than he got, or maybe got a slightly better spending/tax cut split, but he did pretty well, and I don’t think the difference between what he got and what he ideally could have gotten was enough to affect the economy.

      I don’t think he could have gotten a second stimulus through, particularly at the point it was apparent (or they were willing to admit) that it was needed. Maybe he could have gotten a few tailored spending bills for popular items, but the effort would have distracted (and probably derailed) healthcare, so it wasn’t worth it.

      On health care, there was no way he would get true single payer (forget about destroying an industry, people with employer-sponsored healthcare would have freaked about having their insurance and compensation packages meddled with) so it wasn’t even a viable threat.

      But what I do wonder about was Lieberman’s proposal and subsequent opposition to extending Medicare to 55. First, if we lived in a pre-blogosphere age, would that have gotten into the bill? (He seemed to only turn on it when it became clear that liberals liked it.) It also makes me wonder if there wasn’t more play in the conservative Dems’ positions. It didn’t seem like they had specific policy objectives beyond making the bill less liberal. I know I’ve heard of film directors adding explicit bits to their movies to get the ratings board to demand they be taken out as cover for the stuff the directors don’t want touched. It’s true, Obama and his allies didn’t have much leverage, but I’m not convinced that Lieberman and Nelson could have been gamed a little better.

  • TT

    I think Baucus was an even bigger obstacle throughout ’09 than Lieberman, Landrieu, Nelson, or Bayh in that he controlled the relevant committee and was determined to conduct his own negotiations with Grassley, Kyl, and Snowe (who were all quite openly admitting that the negotiations were a charade and that they were just trying to extract concessions then scuttle the final product). However, there was absolutely nothing that could be done about it, because if there’s one thing that powerful, long-serving Democratic senate committee chairmen from deeply conservative states love it’s being “told” what to do by a newly-elected Democratic Whiten House.

    • Brien Jackson

      I think the only person in the Senate who was a true “obstacle,” as opposed to having an annoyingly divergent view of tactics that they could make everyone else live with, was Lieberman. It’s pretty clear that, whatever their problems, all of the Democratic Senators were committed to reform that at least addressed the problem of the uninsured, and were always going to support the basic party position at the end of the day. Lieberman being, well, Lieberman was the only wild card.

      • Rarely Posts

        Lieberman’s attitude towards lowering the Medicare age to 55 – for it, until he discovered liberals liked it, then against it – does establish that he was the worst. But was Bayh really committed to reform? I always worried that he could walk away at any time.

        • Brien Jackson

          Bayh was going to be a centrist wanker, but if there was ever any chance of him walking away then he would have voted against the bill’s ultimate passage (he wasn’t running for re-election, after all).

          They might be annoying wankers sometimes, okay most of the time, but for the most part the conservative Democrats in the Senate at least deserve credit for being mostly well meaning types. I’ll never get anyone who hates a Baucus or Bayh but admires Collins or Snowe.

          • Scott Lemieux

            I think this is right. Bayh and Nelson and Baucus, awful as they are, were conservative Dems but willing to advance the general priorities of the leadership and the president, and at least had coherent (if really bad) policy objections. Lieberman was just an asshole for the sake of being an asshole; whatever progressives last got out of the bargain he was going to oppose to stick it to hippies.

            And also, yes, fuck Olympia Snowe. She clearly refused to go along with policies she was almost certainly personally willing to live with and give the Dems some leverage against Holy Joe to keep her powder dry for a race she ended up not running anyway.

    • joe from Lowell

      if there’s one thing that powerful, long-serving Democratic senate committee chairmen from deeply conservative states love it’s being “told” what to do by a newly-elected Democratic Whiten House.

      …run by a guy who was that Chairman’s low-level backbencher two months before.

  • Brien Jackson

    As I said in one of the other threads, I think one of the biggest reasons we were always getting something like the ACA and there wasn’t much that Obama could do to influence the Senators was that a lot of long serving Democratic Senators had been working on the issue for a really long time, all things considered, and the general framework of what the proposal was going to look like had long since been settled (which is why there was virtually no difference in the plans offered by three candidates who had been in the Senate). It’s why the major flex points all involved optics, posturing, and rote political tactics, and not any substantial policy matter.

  • brewmn

    I think a distinction needs to be made between the “Democratic electorate” and the elites who actually control policy. The primary reason Democratic candidates weren’t pushing for single-payer was because they were afraid of the healthcare providers and the insurance industry resurrecting Harry and Louis and torpedoing a single-payer bill (or any reform bill to the left of ObamaCare. Whether the Democratic electorate would have voted for single payer in the absence of that threat is a different question, I think.

    • junker

      I’m not sure I understand. If the electorate and the machinery of the party are that distinct, couldn’t one of the candidates distinguish themselves by pushing single payer?

      If I’m reading you correctly, your claim is that mainstream democrats wanted or were fine with single payer, and the fact that there weren’t any single payer plans is a reflection of top-down influence by party elites. But then why wouldn’t Edwards, say, promote a single payer plan directly to the electorate?

      Bernstein’s point about parties is that you can’t really separate the electorate from the broader party framework like that.

      • Scott Lemieux

        Bernstein’s point about parties is that you can’t really separate the electorate from the broader party framework like that.

        Right.

    • FlipYrWhig

      But I think your points converge. Why fear Big Health? Because they have the power to wreck bolder policy solutions… by altering public opinion. IOW, after the “elites” get done doing what they do, the rank and file electorate doesn’t necessarily still believe in what they started out believing in.

      • brewmn

        [Just came back to the thread.]

        This. A single-payer wouldn’t necessarily kill a candidate’s chances at getting elected, but it would kill his or her chances of getting any meaningful healthcare reform passed once in office. The hyenas would start baying the minute a bill was proposed to Congress.

        If single-payer was imposed by fiat, with no public opposition, I’m guessing it would be very popular with 60%-70% of the electorate. The political and media establishments have spent a shit-ton of time and money convincing American voters that large-scale government benefit programs either can’t work or are simply unaffordable.

  • Incontinentia Buttocks

    I totally agree with this: the problem wasn’t Obama’s position on health care reform (or tactics to achieve it), or even Senate Democrats’ positions on these things, but rather the position of the mainstream of the Democratic Party as a whole. That certainly wouldn’t have been easy to change during the 2008 campaign. But the positions of the Democratic Party, while overdetermined and the product of years of politics, are not natural facts. And it is extremely unfortunate that something like the ACA, rather than Medicare for All, had become the position of mainstream Democrats leading into this round of health care reform.

    • junker

      I wonder if single payer would have been seen as “too far left” compared to the status quo, and that’s why it wasn’t adopted by the party. I think this is why we need to work extra hard now; if the ACA becomes the status quo, then the new left option will be single payer.

      • FlipYrWhig

        Not too far left, but too big a shift for people who already have employer-based insurance. It would trigger all the fears about long lines and less quality. And if the cancellation of a small number of individual policies managed to light the world on fire, think of how fiery it would have gotten if the 80+% of people who already have insurance all had to change what they were used to.

    • jeer9

      I wonder why the Dem leadership hasn’t adopted the increase Social Security benefits strategy. It seems a political winner.

  • Bloix

    “the ACA and the Heritage Foundation plan couldn’t be more different”

    Uwe Reinhardt of Princeton, the most respected and influential liberal health care economist in the US, begs to differ:

    My early introduction to the texts coming from conservative thinking on health reform was the Heritage Plan of 1989, Viewed through the prism of the ACA of 2010, its language seems eerily familiar…

    There then followed a real life health bill based on these ideas, the late Republican John Chafee’s antidote to the emerging Clinton plan. It was called the “Health Equity and Access Reform Today Act of 1993” and had an impressively long list of Republican co-sponsors, among them Senator’s Orrin Hatch (R-Utah) and Charles Grassley (R-Iowa), now fierce opponents of the ACA. As the folks at the Kaiser Family Foundation have shown, many of its provisions of Chafee’s bill have a striking similarity to provisions in the ACA of 2010…

    I know from personal conversations with former Congressman Bill Thomas (R-California) that in the late 1990s he and his colleague James McCrery (R-Louisiana), both of the House Ways and Means Committee, had crafted in the late 1990s a bill encouraging the gradual replacement of employment-based health insurance with individually purchased insurance…

    http://thehealthcareblog.com/blog/2013/08/18/talmudic-like-studies-of-republican-health-reform-ideas/#more-64618

    But hey, Reinhardt is just the most important liberal thinker on health care in the US, what can he know? His belief that the ACA is an adaptation of ideas developed by Republicans just shows his “stupidity,” I guess.

    • Scott desperately wants to spin this point. No amount of facts will deter him.

      • Scott Lemieux

        No amount of facts will deter him.

        Oh, that’s rich. Please go back to Bloix’s post, where you’ll note that it does not cite a single relevant “fact” about the Heritage Plan, because he’s miles in over his head and his argument is obvious nonsense.

    • Scott Lemieux

      My early introduction to the texts coming from conservative thinking on health reform was the Heritage Plan of 1989, Viewed through the prism of the ACA of 2010, its language seems eerily familiar…

      His bare assertions are worth nothing. Where’s the Medicaid expansion in the Heritage plan? The heavily regulated insurance that covers actual routine medical care? Where was the voucherization of Medicare in the ACA? There’s a reason you’re resorting to arguments from authority rather than arguments on the merits — you don’t have any response on the merits.

      I also note that Reinhardt’s quote is not at all responsive to my post, because it concerns a point not under dispute — both plans have a mandate. But, again, 1)the Heritage Foundation didn’t discover the free rider problem and any plan proposed by anyone would have a mandate, and 2)that’s where the similarities end with most of the crucial issues still left on the table. But, in fairness, you have rebutted the zero people who have ever argued that the ACA set up a single payer system!


      Republican John Chafee’s antidote to the emerging Clinton plan
      .

      Again, this egregious bait-and-switch is just as much bullshit as it was two days ago. Chafee’s plan, while not nearly as progressive as the ACA, was very different than the Heritage plan, and citing someone far to the left of the typical Republican even in 1993 as if he represents the typical Republican is an argument made at a farcical level of bad faith.

      Senator’s Orrin Hatch (R-Utah)

      Jesus Christ. Right, Orrin Hatch was definitely committed to Chafee’s plan, which is why the GOP enacted it as soon as they took power in 1994. Your number must be a very valuable lead for telemarketing scams.

      • I’ll also note that the key context is that Reinhart is trying to beat the Republicans for opposing the ACA. This is a context where of course you are going to say that the ACA is Republican, or based on the Heritage plan, etc. etc.

        Even there he primarily focuses on the mandate (which, after all, was a focal point of attack, cf broccoli, government compels you to eat).

        So…I’m not sure what this appeal to authority is intended to accomplish.

        But if we’re appealing to authority! I happen to have Stuart Butler right here!

        The confusion arises from the fact that 20 years ago, I held the view that as a technical matter, some form of requirement to purchase insurance was needed in a near-universal insurance market to avoid massive instability through “adverse selection” (insurers avoiding bad risks and healthy people declining coverage). At that time, President Clinton was proposing a universal health care plan, and Heritage and I devised a viable alternative….

        My idea was hardly new. Heritage did not invent the individual mandate.

        But the version of the health insurance mandate Heritage and I supported in the 1990s had three critical features. First, it was not primarily intended to push people to obtain protection for their own good, but to protect others. Like auto damage liability insurance required in most states, our requirement focused on “catastrophic” costs — so hospitals and taxpayers would not have to foot the bill for the expensive illness or accident of someone who did not buy insurance.

        Second, we sought to induce people to buy coverage primarily through the carrot of a generous health credit or voucher, financed in part by a fundamental reform of the tax treatment of health coverage, rather than by a stick.

        So there you have it!

        (Obviously not. I think Stu is probably spinning, but it’s worth evaluating his own claims.)

        • IM

          Second, we sought to induce people to buy coverage primarily through the carrot of a generous health credit or voucher, financed in part by a fundamental reform of the tax treatment of health coverage, rather than by a stick.

          The same could be said about ACA though, the mandate is if anything quite weak.

          • I think I agree.

            As I said, the mere fact that Stu is claiming a huge difference between the mandates isn’t itself evidence that there is one: He clearly has a huge incentive to claim otherwise.

      • Malaclypse

        Also, Chafee’s plan had “medical malpractice reform” as a big component in cost control. It says something about Dilan and Bloix that, when they see a Republican say “tort reform” they don’t see the scam.

        • I don’t think the concept of medical malpractice reform is a scam. Some forms of it are, like the damages caps we have in California. But would I rather have a compensatory no-fault system for it rather than a damages lottery? Sure I would.

          Having said that, what you are saying is that just like Obama attached his riders, Heritage attached theirs. The core of the bill was the same.

          Here’s Heritage praising Romney’s signing of the bill in Massachusetts:

          “Outside observers on both the Right and Left praised the program. Edmund Haislmaier of the Heritage Foundation hailed it as ‘one of the most promising strategies out there.'”

          http://www.cato.org/policy-report/januaryfebruary-2008/lessons-fall-romneycare

          And here’s Romney thanking Heritage, who sent a representative to the bill signing:

          http://thinkprogress.org/health/2012/04/12/463097/romneycare-6/

          But hey, I know, it was all Democrats.

          Scott, at some point “spinning” and “lying” converge. I’m not one of those calling this a pure Republican idea. But the idea that it has nothing to do with Heritage is ridiculous. It’s a lie.

          • Scott Lemieux

            The core of the bill was the same.

            Again, this is just ridiculous.

            The fact that you’re citing the Heritage Foundation praising the likely Republican nominee for president speaks for itself. And since they stridently opposed the ACA, by your own metric your point is disproven.

            • So it’s OK to cite a Heritage official opposing Obamacare, but it’s not OK to cite a Heritage official praising Romneycare?

              This is heads I win tails you lose. Scott, you really are better than this dishonesty. Take a step back and realize it won’t hurt your political position to acknowledge that Heritage and Republicans had some role in the pedigree of Obamacare.

              • Scott Lemieux

                So it’s OK to cite a Heritage official opposing Obamacare, but it’s not OK to cite a Heritage official praising Romneycare?

                No, I’m saying they’re both completely irrelevant, because they’re political arguments not arguments about policy. If you actually compare what’s in the Heritage policy in the ACA, they’re radically different, so who gives a shit what they say when they’re trying to prop up Romney or attack Obama? You on the other hand, are flagrantly hackish — nominal Heritage support of the health care passed by Massachusetts Dems counts, criticism of the ACA doesn’t.


                Heritage and Republicans had some role in the pedigree of Obamacare.

                I think the goalposts just passed Pluto.

    • joe from Lowell

      Do you realize that you didn’t cite a single fact, or provide any description whatsoever, of what was in either of plans?

      That your entire argument is an appeal to authority?

      Scott actually discussed what was in the plans – the difference between limited catastrophic coverage vs. comprehensive coverage, expanding Medicaid vs. privatizing it, etc.

      You’ve had days to respond to these facts, and I can’t help but notice that you’ve got nothing. Just opinion.

    • joe from Lowell

      There then followed a real life health bill based on these ideas, the late Republican John Chafee’s antidote to the emerging Clinton plan. It was called the “Health Equity and Access Reform Today Act of 1993” and had an impressively long list of Republican co-sponsors, among them Senator’s Orrin Hatch (R-Utah) and Charles Grassley (R-Iowa)

      …a bill that never came to the floor, by order to the Republican leadership, either in 1993, or in any year in which the Republicans controlled one or both houses of Congress.

      But they sure did support it.

  • Anonymous

    Just ask, “So the Heritage Foundation wanted to expand Medicaid to cover all single adults in poverty?” Argument OVER.

    The Medicaid expansion is the central pillar of ACA in terms of expanding coverage, even though it gets less press than…well, everything else in the ACA. Sadly, it’s one piece they might have been able to sell better as a standalone piece of legislation. Republicans now reject it to “stand against Obamacare” while Obama could have used it to deflect criticisms he doesn’t care about poor people. I still think every state will eventually accept the expansion one day or another (I’d bet good money Rick Perry does an 1115 waiver before he leaves office), but it might have been an easier sell on it’s own. But since Obama was politically toxic to Republicans since roughly 4 weeks after taking the Oath of Office, maybe not. And I don’t know how you sell guaranteed issue, the prevention mandate, IPAB, the exchanges, etc except as part of one big package.

    • Ronan

      Why ant everyone just agree that the Heritage centre hit on a good idea for once?

      • Interferes with the spin.

      • LeeEsq

        Politics.

      • Scott Lemieux

        Why ant everyone just agree that the Heritage centre hit on a good idea for once?

        Because it wasn’t in the Heritage plan, which in fact wanted to welfare reformize Medicaid?

        • Ronan

          Im not saying it *was* the same plan
          Just unusual that Heritage had a half decent idea

        • Ronan

          Ah I misread you. I see what you mean. Their plan wasnt even any good.
          Its interesting how this narrative took off

      • joe from Lowell

        Because private catastrophic insurance, by itself, isn’t all that great. You’ve still got people who end up in emergency rooms because they can’t see a PCP.

    • One problem with this analysis is that the Medicaid expansion is in many ways a separate bill.

      It’s like saying a politician opposes a highway bill because he opposes an abortion rider tacked on. The main structure of the bill was Heritage’s.

      • junker

        Wow, now that is world class moving the goal posts!

        Now, someone with intellectual honesty might look at the fact that the ACA contains some substantial differences from the original Heritage plan and conclude that it’s a different plan. Not our Dilan Esper! Instead, he decides to split off the parts of the law that are inconvenient to his argument and try to pretend that they aren’t relevant.

        Please, take a victory lap!

        • FMguru

          If you systematically ignore all the ways the ACA is different from the Heritage proposal, you’ll clearly see that they’re exactly the same thing!

          • If you systematically ignore the core provisions that Obamacare borrows from Heritage, you will conclude they have nothing to do with each other.

            • Scott Lemieux

              Dilan:

              If you systematically ignore the core provisions that Obamacare borrows from Heritage, you will conclude they have nothing to do with each other.

              The OP:

              The only important thing that the Heritage Foundation’s never-serious plan to force every non-healthy adult to pay for unregulated catastrophic insurance while destroying Medicare and Medicaid has in common with the ACA and MA health care reform is the mandate.

              Whether Dilan is lying or didn’t read the post I don’t know, but it’s certainly one or the other.

              • No, you are dissembling. Your entire argument is that the mandate is some minor feature that’s in every health care plan (which isn’t true– Hillarycare had an employer mandate instead) rather than a distinctive feature of Heritage’s plan that was recognized as such when Romneycare was passed and was actually TOUTED as a Republican idea by Obama when he was selling the Obamacare legislation to the public.

                The mandate is a major, big deal. It’s a key part of the legislation. Without it, the whole thing unravels except for the Medicaid expansion. And it has a partially Republican pedigree, which you are going to great lengths to downplay.

                • Scott Lemieux

                  The mandate is a major, big deal. It’s a key part of the legislation.

                  Nobody’s denying that. But the idea wasn’t original to Heritage and in every other respect the plans are vastly different.

                • Wasn’t original to Heritage? What do you mean by that? Did Nixoncare have a mandate? Hillarycare? Do single payer and NHS proposals have mandates?

                  It seems to me that the INDIVIDUAL mandate to purchase PRIVATE health insurance entered US political discourse as a response to the Hillarycare employer mandate. Prove me wrong on THAT or shut up.

                • Scott Lemieux

                  Do single payer and NHS proposals have mandates?

                  Again, you’re valiantly arguing against the zero people who think that the ACA was single-payer.

                • junker

                  Don’t HHS and singlepayer systems have mandates? I mean, someone enlighten me: Are people allowed to opt out and go without healthcare in exchange for lower taxes? Because I’m pretty sure that any serious public health plan has to have a mandate, which is the point.

                • PhedUp

                  Yes single payer and the NHS have mandates.

                  They’re called taxes.

                  Simple answers to stupid questions.

            • FMguru

              Those goalposts have now reconfigured themselves into…a tripod? a trapezoid? It’s really hard to describe.

              Christ, you’re thick.

      • Scott Lemieux

        This is classic:

        Interferes with the spin.

        One problem with this analysis is that the Medicaid expansion is in many ways a separate bill.

        To accuse someone of spin and then immediately proceed to argue that the Heritage plan and the ACA are the same as long as you ignore the fundamental ways in which they’re different…just wow. Look, the Medicaid expansion was a fundamental part of the ACA, not a separate bill. And were you to read the Heritage plan for the first time, you’d see that the destruction of Medicaid is a crucial part of their plan — gets it own chapter and everything. To treat them as entirely independent issues is dishonest spin of the first magnitude.

        • All legislation is logrolling, Scott. And then people decide whether to support the final product.

          There are many examples of people of both parties opposing bills that, in the main, they support, because of one provision.

          So Heritage didn’t want Medicaid expansion. How does that prove Heritage had no connection to the mandate provision?

          • Scott Lemieux

            All legislation is logrolling, Scott. And then people decide whether to support the final product.

            Indeed. And this is exactly as true of the mandate as it is of everything else in the ACA, so what? Why don’t we equally arbitrarily define the Medicaid expansion as the core of the ACA and the mandate as the “rider”?

            So Heritage didn’t want Medicaid expansion. How does that prove Heritage had no connection to the mandate provision?

            It would help if you would read the fucking posts before commenting, although I can see why you’d rather argue with a pure strawman that engage in anyone’s actual argument.

            • Why don’t we equally arbitrarily define the Medicaid expansion as the core of the ACA and the mandate as the “rider”?

              Because without the Medicaid expansion, the mandate, regulate, and subsidy system can still function. Without the mandate, the bill creates an insurance death spiral.

              • Scott Lemieux

                Well, kinda, which just proves that there’s nothing about the mandate that’s owned by the Heritage Foundation. Nonetheless, the Medicaid expansion was crucial to the passage of the ACA and crucial to its goals. You believe that the Heritage plan and the ACA are fundamentally similar only because unlike the architects of the ACA you’re wholly indifferent to the working poor and apparently can’t understand why anyone would see addressing their goals as important.

                • I think addressing their goals is crucially important, and indeed, did not require any sort of mandate-and-exchange system. Is it your contention that no Medicaid expansion could have passed without an individual mandate and exchanges?

                • Scott Lemieux

                  I think addressing their goals is crucially important, and indeed, did not require any sort of mandate-and-exchange system. Is it your contention that no Medicaid expansion could have passed without an individual mandate and exchanges?

                  I have no idea. But the expansion of Medicaid is in fact an crucial part of the ACA and you can’t just pretend that it’s not there because it suits your hack purposes.

                  Also, there’s no way you can claim that a Medicare buy-in is better policy than the ACA without placing virtually no weight on the interests of the working poor.

            • It would help if you would read the fucking posts before commenting, although I can see why you’d rather argue with a pure strawman that engage in anyone’s actual argument.

              It would help if you stop whining about people talking about the Republican pedigree of this plan if you actually admit it has one. If you really admit this, you’ve wasted quite a lot of time shouting down as dishonest people who are pointing this out and a lot of time misleading your blog readership.

              • Scott Lemieux

                Why on earth would I concede this when you’ve provided no evidence for it? Sharing one thing in common doesn’t make the ACA a “Republican plan,” period.

              • Republican “pedigree”. I chose my word carefully, Scott.

                • IM

                  The drop of blood rule is still alive in american politics.

                • Scott Lemieux

                  Republican “pedigree”.

                  Really? Can you point to the Republicans who supported the Medicaid expansion, or the tougher regulation of insurance interests?

      • JKTHs

        Just having a mandate isn’t the only determinant. There’s also what benefits the mandate involves, what the avenues of coverage are, and how and whether people are subsidized. In Heritage’s case, the benefits were much narrower and the avenues of coverage were all privatized everything whereas the ACA maintained and expanded to some extent existing public programs.

      • sibusisodan

        the Medicaid expansion is in many ways a separate bill.

        Please to name at least some of the ways.

        • 1. It sets up a separate health care system, outside of the exchanges and outside of the private health insurers, for delivery of care for poor and working class people.

          2. It is financed by a different mechanism (general revenues rather than tax credits and co-pays and premiums).

          3. It does not guarantee the same level of coverage (recipients are basically limited to the relatively small number of providers who accept Medicaid, and are not given a network of providers, minimum coverage mandates such as are included in bronze plans, etc.).

          4. It’s totally severable from the rest of the bill (indeed, the Supreme Court did sever it, and you could totally imagine passing a Medicaid expansion without having to impose a mandate or create exchanges or anything else; that makes it very different than the individual mandate, which is needed to ensure the other provisions of the bill could operate).

          • sibusisodan

            Those explain how it’s different from the rest of the legislation, not how it’s separate from it. It plays a part in the overall design of the bill.

            While it could have been passed independently, it was not, and I don’t think that’s pure happenstance.

            • Those explain how it’s different from the rest of the legislation, not how it’s separate from it. It plays a part in the overall design of the bill.

              So does the Stupak amendment. But it’s still severable and a rider.

              • Scott Lemieux

                So does the Stupak amendment. But it’s still severable and a rider.

                Every individual component of the Civil Rights Act of 1964 was potentially severable. That doesn’t make it fundamentally identical to the Civil Rights Act of 1957.

                • True. But it does mean that any prior bills or proposals that contained prohibitions on discrimination in public accomodations, education, and employment were precursors of the bill, even though they may not have contained all the same provisions.

      • joe from Lowell

        Quick, Dilan, describe the main structure of the Heritage plan.

        • Scott Lemieux

          describe the main structure of the Heritage plan.

          Come on, everyone knows that it’s just “there should be a mandate xthxbi” scrawled on the back of a cocktail napkin, with absolutely no other policy proposals integral to the framework.

        • A mandate to purchase a catastrophic health care plan (that has higher deductibles than an Obamacare bronze plan) along with subsidies in the form of tax preferences for individuals to buy insurance, and a repeal of the employer tax credit and caps on medical malpractice damages.

          Did I get it right?

          • Scott Lemieux

            No. Inter alia, you’re forgetting the destruction of Medicare and Medicaid, an omission that’s particularly glaring since it’s convenient to your absurd contention that the issues are entirely independent.

            • Heritage definitely wants to destroy Medicare and Medicaid, but was that part of their proposed alternative to Hillarycare (which is what we are talking about) rather than the subject of separate policy papers?

              • Scott Lemieux

                So, to be clear, you’re defending the Heritage plan as essentially identical to the ACA although you haven’t read the plan, and you’re commenting on multiple posts without having read them.

                • I went back and read it. They did want to fold Medicaid into their mandate and subsidy system. Not sure if that destroys Medicaid or not; a lot of liberals have proposed this too.

                  On Medicare, they wanted to reduce benefits for medical care but institute a system of nursing care insurance. That’s probably a net wealth transfer towards the affluent, but it’s not exactly gutting Medicare; again, many liberals think it should address skilled nursing care.

                • Scott Lemieux

                  On Medicare, they wanted to reduce benefits for medical care but institute a system of nursing care insurance. That’s probably a net wealth transfer towards the affluent, but it’s not exactly gutting Medicare; again, many liberals think it should address skilled nursing care.

                  Apparently, you didn’t make it to page 85, where they propose turning Medicare into a voucher system.

                • Politifact

                  Apparently, you didn’t make it to page 85, where they propose turning Medicare into a voucher system.

                  Well, that’s hardly gutting Medicare, is it?

                • Lee Rudolph

                  Well, that’s hardly gutting Medicare, is it?

                  Only in the sense that performing any act of taxidermy is, before all else, gutting.

                • Scott Lemieux

                  Well, that’s hardly gutting Medicare, is it?

                  Sorry for repeating the lie of the year.

                  Of course, Dilan is a man of principle and the Spokesman of the Left, so if Obama proposed voucherizing Medicare Dilan would see this is a minor matter, perhaps worth opposing but just a trivial “variation” on the status quo. And if Zell Miller and Joe Lieberman favored it, this would prove the plan has a well-established Democratic pedigree.

                • joe from Lowell

                  They did want to fold Medicaid into their mandate and subsidy system. Not sure if that destroys Medicaid or not; a lot of liberals have proposed this too.

                  Such as…?

          • joe from Lowell

            Yes, which means you were lying when you said it was the same structure as the ACA, since catastrophic coverage is so profoundly different from actual health care coverage.

    • Ian

      The Medicaid expansion is the central pillar of ACA in terms of expanding coverage, even though it gets less press than…well, everything else in the ACA.

      This is one of the strangest parts of the whole thing. Before the Roberts court took the axe to the expansion, the CBO estimated that 13 million new people would qualify for Medicaid in 2014, which dwarfs the estimates for those using the exchanges. Even now, the estimate is 7 million, which is still larger then the likely number of exchange users.

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  • Quindice

    Every piece of the ACA was fought over in some way — exchanges, individual mandate, small business tax credits, Medicaid expansion (which may eventually be the biggest expansion of public coverage since the program’s creation). Every vote in the House and Senate had to be won, and this didn’t happen only through Democratic elite politics or some vague reading of a vague electorate. There is a relationship between politics and policy, but it’s more complicated than assessing what was possible at x time, because the relationship isn’t static. I am a supporter of ACA and worked very hard for its passage. I saw the bill as providing an opportunity for pushing both policy and politics to the left. I have questions about whether the President took all those opportunities, particularly given the way the WH interacted with community organizations, but maybe that wasn’t his goal, and maybe I don’t understand the particular calculations involved. However, we should acknowledge that leadership involves not just understanding where the politics are on a particular issue but also trying to shift those goal posts. Seeing how that played out — and still is playing out — with the ACA requires a closer examination than what’s happening in the Gourevitch post or here.

  • joe from Lowell

    leadership involves not just understanding where the politics are on a particular issue but also trying to shift those goal posts

    Those are both important elements of leadership, but it a mistake to think they should, or can, both be pursued to their maximum degree at all times.

    Sometimes you push your chips into the pot to win more chips, and sometimes you should pick up your chips and cash them in.

    • Quindice

      Well, sure, there has to be strategy. But we haven’t been talking about that — I think it’s what missing from the conversation generally.

  • I’m gonna do a little tribute-to-a-friend blogwhoring here. I have a whole lot of sympathy for lefty types grousing about the ACA, but if the practical effect of it is that more people are better off, the ACA a good thing.

  • PhedUp

    If the downside to not having insurance or being unable to purchase insurance due to pre-existing conditions is so “slight,” then where is the urge to have any sort of reform including single payer? No insurance is no insurance whether it’s not paid for through taxes or not paid for through after tax dollars.

  • guthrie

    Here’s a silly question – do you know how the bribes, sorry, campaign finance from healthcare companies was being distributed before and after the Democratic candidates adopted ACA as their preferred choice?

    • Hogan
      • guthrie

        So the industry increased its payments to Democrats running up to the 2008 election? How much did that affect things? Here in the UK our corruption is done differently so it doesn’t map so much onto the money that comes in, but in the USA it all seems so closely linked.

        • Hogan

          It probably reflects the fact that they thought Obama would win and wanted to stake out a claim to some influence in the HCR process. Whether they got what they wanted is another question, and the fact that their contributions to Democrats went down suggests an answer.

          • Hogan

            Went down after 2008, I mean.

        • joe from Lowell

          So the industry increased its payments to Democrats running up to the 2008 election?

          Big industries like Wall Street and the Insurance companies typically donate to both sides, in order to have connections no matter who wins. When one party is clearly going to win, they shift their donations to the expected winner.

          Hence, the big tell is the low donations to the Democrats during the 2012 cycle. The Democrats were very likely to win, but the industry strongly favored the Republicans. That’s your significant data point.

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