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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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