Home / General / The ACA Was Not A “Republican” Proposal

The ACA Was Not A “Republican” Proposal


As promised/threatened yesterday, my longer piece on why it’s both wrong and pernicious to argue that the ACA was based on a Republican proposal.

A couple additional points:

  • Although I left the argument to my linked original piece, several people on Twitter have brought up John Chafee’s 1993 proposal as proof that the ACA had Republican origins (which Moore, to his credit, didn’t.)  To reiterate the obvious, this argument has two fatal flaws.  First of all, the Chafee proposal, which didn’t have a Medicaid expansion, is substantially worse than the ACA.  And even more importantly in this context, Chafee’s health care proposal was exactly as much a “Republican” proposal as Chafee’s proposed federal handgun ban.   The Republican offer to the uninsured in 1993 was identical to the one in 2014: “nothing.”
  • It’s peripheral to my main point, but it’s also wrong to say that the ACA is a “pro-insurance-industry plan.”  The insurance industry, which spent several million dollars opposing it, was under no such illusions — it was doing just fine under the status quo ante.  The idea that the health insurance industry was going anywhere absent the ACA is bizarre, and while the ACA was more favorable to the health insurance industry than the politically impossible creation of a single-payer system would have been, it wasn’t more favorable than what existed in 2008.
  • I understand that the “ACA was a Republican plan” line is, if anything, more common among ACA defenders than opponents.      (E.J. Dionne made it earlier in the week.)  But that the argument is well-intentioned either way doesn’t make it any less wrong and counterproductive.  Particularly with the constitutional challenge to the mandate having been settled, there’s nothing to be gained by a line of argument that both implicitly understates the progressive content of the ACA and explicitly gives Republicans credit they manifestly don’t deserve.  Whether the ACA is “liberal” in some absolute sense, in the context of American politics it clearly is.  We can discuss the merits and defects of the ACA without imagining a moderately progressive national Republican Party that has never existed, and we should.
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  • Ronnie Pudding

    I understand that the “ACA was a Republican plan” line is, if anything, more common among ACA defenders than opponents.

    It was used to tweak Republicans who claimed Obama was an ultra-liberal. A bit like pointing out that it was Dubya who signed the light bulb law (although that is, in fact, true).

    • Brandon

      “How can it be a socialist takeover of healthcare if it was proposed by Republicans in the first place?!” was one version, as well as “Republicans will reject their own policy proposals if Obama agrees with it, so of course he can’t negotiate with them!” was another.

      But what Scott’s often pushing back against is the “he.didn’t.even.try” attacks on PPACA from the left that cast it as a complete sellout by Obama to conservative policies when more progressive policies were viable.

      • Scott Lemieux

        Right, although I think this rhetorical use of the “it was a Republican plan” argument is ultimately as counterproductive as the “he. didn’t. even. try!” argument.

        • Pat

          And it’s nowhere near as funny.

        • njorl

          I believe the “mandate” was a Heritage idea, or was at least popularized by Heritage. Using this approach against Republicans who challenge the concept of the mandate is rhetoically sound.

        • joe from Lowell

          In the context of 2009, it made sense as a line for Democrats to use.

          Now that it’s been adopted, though, the line does not good and some harm.

          • The thing is, quite apart from the fact that I think the line is more true than Scott does, if people repeat something over and over again, it makes it hard to walk back the claim.

            In other words, even if we assume that Obamacare had no Republican roots, if enough Democrats up to and including the President said over and over again that it did, that’s a claim that probably cannot be walked back. Call it “political estoppel” or something.

            • even if we assume that Obamacare had no Republican roots

              Nobody’s asking you to make that assumption.

            • joe from Lowell

              if people repeat something over and over again, it makes it hard to walk back the claim

              Well, it makes it hard for that person to walk back the claim.

              In 2017, when the next President takes office, the ACA will be seven years old, and the new President will be able to frame the health care issue anew.

            • joe from Lowell

              The next time health care reform comes up as an issue, Dilan, we won’t be arguing about the ACA and where it came from. We’ll be talking about the status quo and how it could change.

  • Gwen

    Why can’t we just say that the most unpopular part of the ACA, the individual mandate, is the one GOP contribution to the bill?

    Surely that is a more politically potent than caterwauling about how the Republicans are meanies for attack “their” own bill.

    • personally, whenever i hear a complaint about the individual mandate, i say “do you like the idea that you can be denied coverage for a pre-existing condition?” and “do you like the idea of recission?”

      since the vast majority of people don’t, that provides an opening to note that you can’t get rid of those two problems without the individual mandate to keep the system from being gamed.

      the people i’ve had that discussion with still may not like the individual mandate, but at least they see where it’s coming from.

      which i think is a whole lot better than saying “it’s the gop’s fault.”

      as scott has rightly noted in this little series, the aca is a progressive piece of legislation: progressives should defend it, not crouch in a corner blaming the gop.

      • Denverite

        that provides an opening to note that you can’t get rid of those two problems without the individual mandate to keep the system from being gamed

        This isn’t actually true. There are a number of mechanisms that you could use to try to stop people from waiting until they anticipate costly medical care. Annual enrollment windows, for example.

        • Scott Lemieux

          The mandate is, I think, clearly better than the alternatives. Do you really want people to not be able to obtain insurance because they’re not informed about deadlines?

          • Denverite

            I don’t disagree. Just pointing out that the mandate wasn’t the “only” way to stop death spirals.

            • i’m happy to be convinced otherwise, but i don’t see how annual enrollment windows solve the problem in the way that the mandate does. perhaps you could elucidate?

              • Denverite

                Death spirals primarily are caused when most of the people signing up for insurance do so because of high anticipated health care costs. One way to prevent that is to require people who don’t have that expectation to sign up (e.g., a mandate). Another is to put barriers in the way of people who expect to have high costs — for example, by excluding people with preexisting conditions, either altogether (as was the case on the individual market), or for a period of time (like in the employer market). This works in two ways. First, it keeps them out of insurance pool for however long the barrier is in place. Second, it incentivizes (rational) people to purchase insurance before they expect high health care costs.

                Anyway, an annual enrollment window (say like the first two weeks of January) would do both of those. If you went without insurance and got sick in say March, you’d have to wait ten months to get insurance. This means that any care you received during that time is uninsured, and maybe you’d die before you could sign up. That both saves money for the insurance pool, as well as gives you an incentive to get insurance before you get sick.

                Now, Scott’s right that the mandate is better in theory (for the obvious reason presented by my get-sick-in-March hypothetical). In practice, given the smallish ACA penalty and the doubt over whether the IRS is even going to enforce it in most cases, I think it’s an open question as to whether it will work as well — but that’s an empirical question, and we’ll know the answer to it in the next decade.

                • HOw would this work in practice given that we also had enormous costs due to the use of the ER by people without health insurance at all? Since people don’t have to sign up for health insurance at all there were unisured and sick people whose care fell on the charge of the taxpayer or who ran up bills of various kinds without the means to pay for them. The mandate doesn’t take the place of the open enrollment period/closed application period. It penalizes people who think they can go naked.

                • NonyNony

                  Since people don’t have to sign up for health insurance at all there were unisured and sick people whose care fell on the charge of the taxpayer or who ran up bills of various kinds without the means to pay for them.

                • Denverite

                  Aimai —

                  I guess I don’t understand what you’re asking. Providing ER care to all comers and avoiding insurance death spirals are two very different phenomena.

                  As for the mandate, you are correct that it imposes costs on people who go without insurance. So does declining coverage for people with preexisting conditions. So does making people wait to sign up for coverage until a preset window.

                  If the goal is to have a workable health insurance model, the two questions we need to ask are (1) how effective are those costs in preventing death spirals, and (2) how humane or equitable are they? Scott says that the mandate is clearly the best; I suspect that’s because it scores much higher on the second question. I don’t disagree. My only hesitation is that I wonder whether the way this particular mandate is structured makes it score low on the first one. But time will tell.

                  In any event, I was merely responding to howard’s statement that the mandate was the only way to go about achieving the goals of the ACA. It wasn’t — though it probably was the best. This shouldn’t be controversial; there’s a ton of literature on it. (It also is why Obama could be “anti-mandate” with a straight face in the 2008 primary — he could say that maybe we’d use one of the other mechanisms.)

                • howard

                  denverite, i think this brings us to the heart of the matter: is it possible to imagine a non-mandate solution actually working?

                  i can’t, so in a sense, yes, i do believe the “only” approach is the mandate.

                  now, whether the aca’s mandate is the platonic ideal of mandate policy? on this, i don’t know enough to say.

                • Manju

                  It penalizes people who think they can go naked.

                  “Penalize”? “Go naked? Coincidence? I think not.

                • I think the idea of an insurance “death spiral” is an artifact of the private insurance model in which coverage is optional and the risk is spread across a group that is, in fact, smaller than the entire country. If we could have shifted directly to a full insurance model, in which everyone got insurance/coverage by virtue of being a citizen and had to pay in with taxes we’d have an effective mandate (everyone pays in) and we would have no “death spiral” because no person could opt our, or would be forced to opt out, only to opt in when they cost the most. Premiums/mandate/taxes would be the same thing.

                  I’m pointing out that the mandate is meant to prevent people from choosing to save money by opting out/refusing health insurance by making it costly to do so. But its notional unless they are going to be barred from receiving any care if they don’t have insurance–and its notional because the amount is, in fact, notional at the moment rather than being the equivalent of a bronze plan. The mandate doesn’t cover the difference/pay for the health care in the event of a disaster. Its just a way of trying to induce an individual to purchase the health care they are resisting purchasing.

                  The system may or may not go into a “death spiral” where there aren’t enough currently healthy people paying into the system to cover the sick people who are paying into the system but whose payments don’t fully cover their costs. But really, we can afford to pay for this shit. We just refuse to see the money we spend on guns and giveaways to the rich as being something we should just go ahead and spend on healthcare. Why healthcare recipients should have to pay for themselves when air craft carriers don’t is beyond me. It costs money to run a health care system and to get health care. It costs so much money its not reasonable to assume that each person can, in effect, pay for themselves or that the entire country can through premiums on the individual.

              • Hogan

                HOw would this work in practice given that we also had enormous costs due to the use of the ER by people without health insurance at all? Since people don’t have to sign up for health insurance at all there were unisured and sick people whose care fell on the charge of the taxpayer or who ran up bills of various kinds without the means to pay for them.

                The care provided for free in ERs, while expensive, is extremely limited; basically if you come in with a serious to life-threatening condition, they’re required to stabilize you, then they’re done for the day.

                A friend of ours once saw a woman in a leg cast sitting on the sidewalk and banging her cast on the curb. Turned out she didn’t have insurance, so when she broke her leg the ER put a plaster cast on it and sent her home. But having a cast on your leg is not a serious medical condition, so she was on her own as far as removing it. (Of course, if she re-broke her leg in the process, she’d be entitled to another cast.) It probably won’t take many experiences like that for people to realize that at least some insurance is a good idea.

                • Malaclypse

                  A friend of mine got cancer. Turns out that emergency rooms do jack fucking shit when you show up and say “hey, I have cancer.”

                  So, fuck anyone who says the poor can always just show up to emergency rooms.

            • Scott Lemieux

              Well, I don’t think anyone argues that it’s literally the only way, so much that it’s clearly the best way.

              • Denverite

                I take howard’s posts to mean that he thinks it’s the only way.

                I do think that “clearly” is maybe a bit strong, at least in this particular case. As I noted immediately above, I think it’s an open question as to whether the ACA mandate penalties are substantial enough to be effective at what they are designed to do.

                • howard

                  for the reasons you point out, denverite, i don’t see that the annual window actually solves the problem, so i do think the mandate is the “only” way to solve it.

                  that may be my lack of imagination or exposure to alternatives, and as has already been noted, in practice, we’re going to end up where you propose, which is to say that some people will ignore the mandate and life will still go on.

                  but i don’t see any way that i, as a profit-maximizing ceo of a health insurance company responsible to a board and to shareholders could possibly accept the idea that i’ve got to insure people with pre-existing conditions but healthy people aren’t required to buy insurance….

            • panda

              If I’m not mistaken, this is exactly the situation today: there is an open enrollment season, and when it’s over, one can only get an exchange due to a qualifying event (losing a job, moving to a different state, etc). In fact, given the very soft nature of the mandate, the open enrollment period is in theory the linchpin of the enforcement system.

              • panda

                In *practice*, not theory.

          • Gwen

            I tend to agree that it may be the best mechanism, and am resigned to the notion that it is necessary.

            That said, a big part of why I supported Obama over Hillary was because he was less enthralled with the individual mandate. (I’m wildly enthusiastic in favor of the employer mandate, fwiw).

            And while I might be able to summon up lukewarm support for it (and cheered the Supreme Court ruling holding it constitutional), I still kinda don’t like it, or at least don’t like having to defend it when visiting my parents. (First world problem?)

            Also, tired of hearing my firebagger friends whine about it.

            • Gwen

              In the long run of course, good policy is good politics. If it’s necessary to make everything else work (and it probably is) then supporting it is the right thing to do.

              That said, in the short-term, policy and politics are much less-tightly coupled, like strangers passing in the night.

              • Gwen

                And (sorry for multi-self-reply-rant), as good Keynesians (and readers of Machiavelli), we should all *know* what happens in the long-run. =)

                • howard

                  gwen, it’s worth remembering the context in which keynes made that remark: he was speaking about the fact that eventually demand recovers on its own because things wear out, so that in the long run, economies can repair themselves.

                  he then notes that that is much too easy a goal because in the long run, we’re all dead: the point is to make improvements in the short run.

                  and in the short run, democrats need to stop being scared of defending the aca: they need to read the poll numbers, assume the haters, and sell the policy to those who might not normally vote in mid-year elections to help keep the thing in place.

                • Manju

                  we should all *know* what happens in the long-run

                  The market end up working.*

                  *yes, that’s what he meant too**

                  **but this is not applicable to Healthcare Economics

                • howard

                  since manju brings the topic up, let me direct interested readers to ken arrow’s definitive 1963 paper on why health care isn’t a suitable application for market economics.

    • Vance Maverick

      Now it’s true, as Scott writes, that the mandate is in the Heritage plan. And it may be true that it’s unpopular. Unfortunately for your proposed strategy, it’s important. The only better approach I can see is to hide it by going to a single-payer plan, so one “purchases insurance” by being a taxpayer.

      • Gwen

        That’s true. And if we had a public option, we could do an “opt-in” strategy in parallel with a private insurance market.

        Rather than this so-called tax penalty, I kinda wish there was a “Medicaid-lite” (or Diet Single Payer) that we could auto-enroll everyone in, that maybe covers just catastrophic care. That you can opt-out of with proof of private (comprehensive) coverage.

    • That’s still parsing really finely, and arguing on the terrain you don’t want to be.

      The smarter political move is to focus on new people being covered, and on the subsidies.

      • Anna in PDX

        True, but I think there has to be some both/and. We both need to show its successes and demonstrate that it has improved life for lots of people (assuming it has) AND push back on counterproductive/untrue arguments against it. Unfortunately, the health care system in the US is byzantine and complicated. So is the ACA because it is dealing with the US system.

        The problem with the arguments about *how* we should discuss it is that we end up spending a lot of time on them, too. What I am really hoping for, and to an extent I am seeing it but only on liberal blogs, is a lot of coverage that tries to explain this to regular people who are not policy wonks but also does not oversimplify it. Arguing about how to cover the health care debate can be just as wrong-headed in terms of the terrain we don’t want to be on.

        I’ve really appreciated Richard Mayhew’s detailed coverage of the ACA and how it affects the real health care market as an industry insider, on Balloon Juice, and also Scott’s and other people’s writings on the politics of it. I think this type of coverage should be pushed to the mainstream media. Maybe sustained “letters to the editor” campaigns? Or guest columns?

        This kind of detail should not take the place of simpler “how the ACA helped me” testimonial type coverage, of course. But I think we should be providing two types of service to the broader public – a) try to influence attitudes about the law and whether it is a good or bad thing, and b) help people get better health care now that the law will help them do that, which means educating them on their choices.

        • mds

          What I am really hoping for, and to an extent I am seeing it but only on liberal blogs, is a lot of coverage that tries to explain this to regular people who are not policy wonks but also does not oversimplify it.

          You better not have been wearing pajamas when you typed this recommendation.

          • Anna in PDX

            Hee hee, even though it is casual Friday I don’t want to go so far I end up unemployed!

  • i think it’s a more open question whether the health insurance industry was better off in 2008 than it is now.

    it’s true, on the one hand, that health insurers had a strong hand: they could deny claims more readily, they could exclude potential customers, and recission was available to them.

    on the other hand, that was a model that was in decline: corporate coverage was declining (according to kaiser, 63% of firms offered health benefits in 2008, 57% in 2013), out of pockets and deductibles were increasing (leading to unhappy workers), and precisely because the individual market was largely broken, it’s not clear that there were replacements for those declines in corporate coverage coming from individuals.

    the aca took away some of the insurance company freedoms, but in return, provided more customers and subsidized those customers in such a way that it’s likely that revenues will increase.

    so i’m not sure it’s cut-and-dried that insurance companies were better off in 2008 than they are now in 2014.

    • Anonymous

      Any industry fights regulation tooth and nail, regardless of its actual effects. Is food safety bad for the food industry? Is the FCC bad for broadcasters? Is auto safety regulation bad for car makers? Of course not.

      The idea that CEOs who oppose regulation are guided by any sort of rigorous cost/benefit analysis, rather than just abusing their position in favor of their own extreme political views, is unsupportable.

      Any decent human being who could actually run a company that competes on quality of product and service would be begging not to have to compete with lowlifes who pollute, maim their workers, and cheat their customers. The fact that this is virtually never said by any executive shows how despicable our business elites are.

      • i don’t disagree with your broader point but there’s a fair amount of evidence that large firms are, in fact, perfectly willing to entertain regulation that they believe will harm their smaller competitors.

        but you’re right: you don’t become a ceo of a major corporation in america because you care about people….

      • Pat

        Well, I think it’s important to understand that everyone has to move together. Everyone includes the insurance companies as an industry, but it also includes the insured population and the healthcare providers (doctors and hospitals). One company electing not to deny coverage would get creamed. A healthy individual paying into the insurance pool instead of buying a car (payments not dissimilar) is hard to envision. Hospitals can devise cheaper delivery systems, but only if they know they’ll get paid. And so on.

        • Anonymous

          Sure, but aside from howard’s quite legitimate point about the misue of regulation to erect barriers to entry, government regulations are inherently everyone moving together.

          My point is, there is no one in the insurance agency saying, “please close this loophole for everyone, we hate screwing our customers that way, but we only use it because even if we don’t all our competitors do”. If that’s too blunt to say out loud, fine, then shut up and accept and quietly welcome the new regulation. Don’t fight it to the bitter end, just because it might mean a slightly smaller jacuzzi on this year’s yacht purchase.

          • Pat

            Not to argue on behalf of the devil, but I’d like to point out that the law of unintended consequences looms largely over the idea of most government regulations. Sarbanes-Oxley, for example, has attempted to address a number of loopholes that Enron leaped to its death through. Its costs are a greater burden to smaller, up-and-coming companies. Its complexity makes it harder for your average Ben and Jerry to build a new company

    • Royko

      I dunno, it’s true that the ACA will provide more customers to private insurance, but a number of them won’t be profitable, even with subsidies. I think they’d take the freedom over the customers, myself. There’s just no money in insuring the sick.

      • NOne of them will be as profitable, given the loss ratio, as selling junk insurance to people who could be screwed out of benefits probably was.

        • howard

          i’m not an expert on health-insurance finances, but my guess is that it’s entirely possible that the rate of profitability on a low-priced junk insurance policy may well be higher but the absolute level of profitability is more ambiguous: on the one hand, you’re taking in $6K/year, let us say, for your customer, and on the other, you’re taking in $16K/year (i’m assuming family plan, junk coverage in one case, aca gold in the other, just for the sake of discussion).

          if i’m making 30% on the $6K and 15% on the $16k, my absolute profits are higher on the latter.

          now maybe the spread of profitability is a helluva lot bigger, but there’s no doubt that under the aca, insurance revenues will be larger: how those revenues play out in terms of profitability is likely, in fact, to take a few years to know so that the actuals can be factored into rate-setting.

          • Denverite

            This varies wildly based on company and product, but I think the general answer to this is that the actual junk products weren’t that profitable, but the producer fees were really high, so it made them attractive for agencies to push. (Imagine a car dealership that sold crappy cars, and the manufacturer got paid about what they cost to make, but then the salesmen got a 25% commission.)

          • Pat

            Exactly. The devil you know is a better deal than the new situation. And human love power, too, which was taken away. So they fought.

            Also consider that companies jockey for position within the industry. In the fight, they are looking for particulars that will benefit them specifically over their competitors. If they can slip those into the negotiations, they will.

      • Sharon

        I think that there is a reinsurance component to the ACA that covers a percentage of the insurance company’s losses for a number of years. I suppose that a bit of googling before posting this comment would have made it more helpful.

    • joe from Lowell

      the aca took away some of the insurance company freedoms, but in return, provided more customers and subsidized those customers in such a way that it’s likely that revenues will increase.

      Sure, but remember the medical loss ratio regulations, that specify how much of the insurers’ income has to go to providing care vs. profit and overhead.

      • howard

        as i noted above, how the revenue increase plays out in terms of profitability remains to be seen, and you’re right to note that effectively we now have a quasi-regulated utility.

        and no less an observer (and fan of profitability) than warren buffett likes regulated utilities, which is why i think it’s an ambiguous question as to whether insurance companies were better off with the status quo of 2008 or the new status quo of 2014.

        • joe from Lowell

          Were the big banks better off with Glass-Steagel or without it? Are they better off with the Volcker Rule or without it?

          I suspect we’d both agree that they are much better off with Uncle Sam forcing them and their colleagues to keep their noses clean, and worse off when it was the Wild West.

          And yet, I can’t quite bring myself to declare the New Glass Steagel Act or the Volcker Rule to be “pro-banker policies,” or say that pushing them is taking the industry’s side.

  • Anonymous

    “We can discuss the merits and defects of the ACA…”

    When does that conversation start?

    I feel like ACA discussions devolve into debates about Obama in general, pretty quickly.

    I’m also afraid that this aspect of the debate will continue past the Obama presidency, as ACA remains the cornerstone of his legacy.

    • joe from Lowell

      So far, yours in the only comment that mentions President Obama.

      • Anonymous

        If that was ever true it’s certainly no longer true. Kind of proving my point.

        Of course, it requires only a little insight to understand that the whole framing of discussion around Heritage plan or not, Republican plan or not, selling the ACA, and what was politically possible back in 2008 is all about Obama, even if his name is not expressly mentioned.

        • joe from Lowell

          Your point is that you can bring up an issue?

          And my notation that you’re the one bringing up the issue proves it?

          Well, yeah, I guess it does.

          • Anonymous

            The threads immediately above this one immediately became all about Obama, and even mentioned his name right away. I had nothing to do with that.

            But if willful lack of reading comprehension makes you feel clever, knock yourself out.

            • Hogan

              The threads immediately above this one immediately became all about Obama, and even mentioned his name right away. I had nothing to do with that.

              You mean those long, detailed discussions about health insurance financing and individual mandate vs. time window for registration were “all about Obama”? And other people have reading comprehension problems?

      • Ed

        They don’t have to. This and other related threads are implicitly about Obama and the choices made during the runup to the passage of the ACA. He also happens to be one of the people who’s always going on about his Republican health plan and how it favors the private sector. It’s a good talking point.

    • Anna in PDX

      yeah, I went through the thread again, and combed it for references to Obama. And you are wrong. It is true that his administration is very involved in getting the ACA passed, so not surprising his name would come up, and I did find one or two comments that mentioned him, but really in general this is a long thread with detailed comments that are not about him at all. We’ve mostly been discussing the legislation itself and how it is having an impact on the industry and customers.

      • Pat

        All those details, Anonymous! Boring, huh?

  • It’s also wrong to say that the ACA is a “pro-insurance-industry plan.”

    Well, no; it’s just that it’s a “pro-industry” plan in that it gives the industry a chance to survive (move to the Swiss model; the 80-85% spending requirement making them the equivalent to very prosperous public utilities) instead of dying (single-payer/Medicare for all).

    They might still be able to pay that dude $102MM a year, but it’s not the way to bet.

    • Scott Lemieux

      gives the industry a chance to survive

      Again, this assumes that the industry in 2008 was in any danger of not surviving, and I have no idea what the basis for that could possibly be.

      • Denverite

        I mean, I guess you could construct an abstract argument that fee-for-service health care was getting so expensive so quickly that at some point soon the only way to make health insurance affordable for the vast majority of people would be an integrated MCO model like Kaiser, thus driving most third party payors out of business.

        But even assuming all that to be true, that point was still decades off.

        • howard

          i agree: there is no reason that the industry couldn’t have remained profitable simply covering smaller numbers of people, although in a situation like that you might see a shakeout and not everyone who was in business in 2008 would still be in business in 2018.

          • Pat

            That would have started to drive us towards dystopia, truly.

          • Denverite

            howard —

            This misunderstands what I meant. My point was that by the mid 2000s, health care costs were growing at a rate that far exceeded inflation (that has since leveled off a bit, at least in part due to the ACA). You could see an argument that if they continued to grow at that rate, at some point an insurance model where third party payors simply pay doctors and hospitals and drug companies what they are charging would be unworkable — health insurance would cost so much that only the very, very rich would be able to afford it. At that point, because there are very few very rich people, most insurance companies go out of business in favor of organizations like Kaiser (which isn’t an insurer in any real sense of the word) that employ their own doctors and hospitals and can charge a much lower rate.

            Again, though, while this might be a plausible story, in 2008 and 2009 it would have been decades away.

            • howard

              denverite, my agreement was to scott’s point, not yours (although as it happens, i think yours is valid too, on a different time scale: that is, you can imagine trends continuing on until the tipping point you describe is reached, but that point is far enough away that it’s hard to even discuss seriously in a current political context): the long-term characteristics of the health-insurance market were probably iffy but there was no near-term health-insurance industry crisis in 2008.

  • I am really happy that this is getting some daylight. I’ve been frustrated by the reflexive claim that the ACA is a rewarmed Heritage plan for ages (and that includes when Obama and other proponents make the claim). This idea needs to be dead and buried.

  • TT

    Chafee’s plan, whether Chafee himself realized it or not, was nothing more than a convenient stalking horse for Dole’s overall strategy of killing health reform outright and then blaming it on Clinton not meeting Republicans halfway. Dole’s objective was to kill health reform by, in Packwood’s words, keeping GOP fingerprints off of it.

    (Remember, too, that Dole used somewhat similar tactics when he tried to get an ostentatiously wavering Bob Kerrey to vote against Clinton’s economic plan, i.e. kill Clinton’s plan then join with the GOP to put together a GOP-led “bipartisan” effort. Kerrey, in one of the few admirable acts of his public career, saw that bullshit for what it was and went with Clinton.)

  • Sly

    I understand that the “ACA was a Republican plan” line is, if anything, more common among ACA defenders than opponents.

    In both cases, the argument is made to counter the claim made by the right that the ACA constitutes a socialist policy on healthcare.

    Here’s the underlying problem with that goal: you’re never going to convince the American right that any domestic policy proposed by a Democratic administration/legislature is not socialism, because the American right has no Earthly fucking clue what socialism is.

  • Lee Rudolph

    As promised/threatened yesterday

    In future you might consider avoiding the dreadful solidus, and writing merely “As presaged” or “As adumbrated”. Or, for a touch of class, “As foretold” (optionally extended to “As foretold in the prophecy”).

  • politicalfootball

    Just to stir the pot a little, here’s a comparison of the S&P500 with an ETF that’s heavy in health insurers, starting shortly before Obama’s election.

    It’s not really dispositive, but it’s at least suggestive that health insurers are expected to prosper under Obamacare.

    • joe from Lowell

      Health insurers are insurance companies, financial-sector enterprises that make their profits off the investments they make in between collecting a premium and paying that money out in benefits, just like life insurance companies.

      What that chart shows is that the financial sector was in very deep doo-doo around the time Obama came into office, and bounced back strongly.

  • Sherm

    A very fair and sensible critique of Moore’s op-Ed IMO. When i read it in the Times I saw nothing wrong with it other than the cheap shots on which you focused. One other thing, I think that when critics refer to the ACA as pro-insurance, I suspect that they mean that it’s more insurance reform than healthcare reform.

    • But of course even that is not true. That is: the ACA is also health care reform, not just insurance reform. There are many parts of the ACA that deal with medications/procedures and their efficacy, that deal with creating incentives for better primary care and outreach rather than just fee for service treatment. There are penalties for shoving people out the door of the hospital or ER and having them return within a certain time period (thats an incentive for the hospital and ER to do more than merely stabilize someone and shove them back on the community). There are all the provisions that put a floor under your health insurance policy and make preventitive care and checkups cheaper or free.

      • Indeed, the ACA has been the primary driver of the block money for quality over free for service revolution. It’s not just the explicit incentives: the no bar for pre existing conditions/elimination of recessions put a big incentive to limit costs by improving outcomes/making people healthier.

  • Solar Hero

    Scott Lamieux, I have been battered by your persistence, prolixity and logic and now I too will admit that the ACA is “not a Republican plan.”

    You have forced me to admit, though, that there is nary a “dime’s worth of difference” between Democrats and Republicans! A Pyhrric victory!

    • Malaclypse

      Still celebrating in Colorado?

    • You have forced me to admit, though, that there is nary a “dime’s worth of difference” between Democrats and Republicans!

      Is there any way this makes even the slightest bit of sense?

      Are you totally unaware of the Tea Party?
      Koch Brothers?

      Seriously – WTF?!?

      • Pat

        Sarcasm, more likely.

  • MNP

    Uh, your second addendum is wrong. Just because they were doing fine or better prior, does not mean Obamacare is NOT also a pro-insurance industry plan.

    • Scott Lemieux

      Just because they were doing fine or better prior, does not mean Obamacare is NOT also a pro-insurance industry plan.


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