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The Arkansas Medicaid Expansion and the Circular Firing Squad

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In this discussion thread, I’ve been having an extensive back-and-forth with Weldon Berger about whether the Affordable Care Act is “conservative.” For the most part, I’m happy to stand by my arguments as stated there — it’s silly to call a statute “conservative” when 1)it advanced longstanding progressive goals to the maximum extent that was politically viable at the time is was enacted, and 2)both before and after the fact actually existing American conservatives (unless you foolishly count some massively unrepresentative New England Republicans*) have never supported anything like it. But there is one point I want to make here.

One obvious contradiction in Berger’s arguments is that he considers the original Medicaid an example of genuinely progressive reform, which makes it hard to explain why a statute that makes Medicaid far more generous can be “conservative.” His answer is that the way in which a single state has been permitted to expand Medicaid renders the Medicaid expansion non-progressive. Combining two comments:

In fact, the administration recently granted Arkansas a waiver to steer newly eligible Medicaid recipients into subsidized private insurance plans offered on the exchange there, thereby treating them exactly as the Nixon and Chafee plans proposed to do. One can expect that the states which rejected the expansion will be looking to the Arkansas model when they finally accept it, and that some states which accepted the expansion will follow suit as well.

You can argue, then, that the Medicaid expansion is more progressive than the Republican plan of simply subsidizing private insurance for low-income people ineligible for Medicaid — as Arkansas is now doing with Medicaid funds courtesy of that waiver from the administration — but you can’t seriously argue that it is a great leap forward in single-payer. Or at least you can’t expect to be taken seriously when you do argue it.

[…]

I said that it’s not the progressive triumph you think it is, and I explained why. The issue with the Arkansas waiver is — again — that it transmogrifies the Medicaid expansion into exactly the policy in the Chafee plan that you regard as laughably inferior to the Medicaid expansion.

The problems with this argument only start with the fact that Medicaid certainly represents a major expansion of single-payer on net. The bigger issue is with the assertion that the Arkansas Medicaid expansion is identical to the Medicaid changes in the Potemkin Chafee proposal of 1993. This is egregiously false, and reflects the persistent problem of collapsing major differences between various regulatory regimes. The Chafee plan sought to encourage states to put Medicaid recipients on the exchanges without expanding coverage. The Arkansas plan approved by the Obama administration, conversely, requires the state to provide coverage to everyone within 138% of the federal poverty line, not just a relatively small subset of the poor. This is not at all the same as the Chafee plan. In my view, all things being equal public helath insurance is better than private insurance, and my guess is that the Arkansas expansion will prove to be less efficient. But it doesn’t follow from that that covering far more people through private insurance required to provide the same benefits as Medicaid is therefore less “progressive” than covering many fewer people through a public insurance program.

The Arkansas medicaid expansion has to be viewed in context. With a legislature dominated by Tea Party Republicans, the choice was not “Medicaid expansion through public insurance” and “Medicaid expansion through heavily regulated private insurance.” The choice was the latter or no Medicaid expansion at all. Now, maybe had the administration denied the waiver Arkansas would have eventually relented, although it wasn’t going to happen in the short term. (The pot of federal money does covert some powerful actors who are normally barriers to reform into potential allies.) But refusing to take that gamble strikes me as sensible. And I’m certainly don’t agree that letting 200,000 poor people go without insurance in the hope that wingnuts will consent to a single-payer expansion is the “progressive” alternative.

But wait — Berger’s argument is worse than that. While it’s true that there are many contexts in which Democrats have been awfully slow to recognize that John Chafee is not, in fact, representative of the Republican Party, this wasn’t one of them. The architects of the ACA anticipated the dilemma that might be posed by red-state Republican governments, and created a funding mechanism that would compel the states to take the Medicaid expansion on federal terms. Only, of course, this mechanism was thrown out by the Supreme Court, leaving a choice between a suboptimal expansion and no expansion in many states. You would think that an allegedly tough-minded progressive critique of health care policy would direct the ire where it’s appropriate — at the unprecedented actions of a reactionary Supreme Court, not at Democratic politicians at various levels doing as well as they can within institutional constraints. But this is a problem with the “ACA is conservative plan” set we’ve observed before — among other problems, they always let the actual villains get off scot-free while training their fire at the wrong targets.

*Several commenters have fairly observed that my characterization of the Massachusetts health care reform as passing over 8 Romney vetoes is misleading. My purpose in this admittedly snarky phrasing was to counter the highly misleading after-the-fact definition of the reform bill as “Romneycare.” I’m not pedantic enough to object to legislation being identified with the executive who signed it when she leads the majority coalition, but a case where the executive was in a subordinate position facing supermajorities of the other party in both houses of the legislature is a different story. But it’s true that Romney was not a steadfast opponent of the legislation — he did act fairly responsibly in a way in which Republicans virtually never do anymore, and he deserves some credit for that, credit my formulation indeed denies him. Still, Romney agreeing to go along with the legislation doesn’t make it a “conservative” or “Republican” proposal any more than Everett Dirksen’s crucial support for the Civil Rights Act made it a “Republican proposal.” If you had to identify the legislation with one faction it would be the legislative Democrats, although the legislation was a collaboration between the branches.

…Relatedly, see Krugman on the importance of Medicaid.

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  • Not Gay Guy

    It’s appalling that any waivers were granted at all.It’s appalling because when any administration has so much power that it can pick and choose who the law applies to and who it doesn’t, it’s simply lawless and imperial.

    • MAJeff

      derp!

      • rea

        Care for a pancke, Ms. Jen?

    • Malaclypse

      Agreed. We are talking about property tax waivers for large corporations, right?

      • Not Gay Guy

        Agreed. We are talking about property tax waivers for large corporations, right?

        That, too

        The position is called rule of law and principle.

        Get some today!

    • GoDeep

      You mean the way the GOP decided ppl selling crack should be treated differently than ppl selling cocaine b/cs the latter were white, but the former black?

      I’m glad BO granted the waiver & I’m glad he’s picking winners & losers. Hopefully you’ll be finding your way to the loser’s corner shortly.

      • Not Gay Guy

        You mean the way the GOP decided ppl selling crack should be treated differently than ppl selling cocaine…

        My state law treats these two iterations legally different and that law was enacted by a legislative process, not an edict of the executive in charge.

    • Scott Lemieux

      Damn Obama for unilaterally enacting Sec. 1905(a) of the Social Security Act into law!

      • DrS

        Does his perfidy know no bounds?

    • Nathanael

      This one (Arkansas) is a legal waiver with provisions in the law allowing for the issuance of the waiver.

      The really problematic things are the illegal waivers, like the “waiver” to allow certain insurance companies to not comply with the out-of-pocket limits. Which is flatly illegal — there is no legal mechanism for those legal requirements to be “waived”. But people are going to get stiffed by this “waiver” anyway.

  • So wait, is the argument that because Democratic Plan A does in one instance behave (due to intervention by the SC) a little bit like Republican Plans B1 and B2, that Plan A is in fact a Republican Plan?

    I actually hope not, because that’s a stinker of an argument.

    • GoDeep

      Yeah, Berger’s argument stinks so much Pepe Le Pew is getting a hard on…

      • DrS

        OT, but since you mention M. LePew…

        What is wrong with his nose that he can’t tell that this cat is not actually a skunk? Does he have a reduced sense of smell or full on anosmia? Interestingly, loss of sense of smell is often linked to reduced libido, and that doesn’t seem to be his problem here. I do believe that lack of sense of smell can be caused by syphillis, so perhaps he’s just acting out of habit.

        • DrS

          Oh, alternatively he’s so fragrant that he can’t even smell anything else.

          That actually seems to fit in with his behaviour, actually.

          • jim, some guy in iowa

            that was what I always got out of it. didn’t the cat’s eyes burn whenever Pepe got too close?

            • DrS

              Yeah, she was not a fan.

        • Lee Rudolph

          Does he have a reduced sense of smell or full on anosmia?

          He needn’t be even slightly anosmic; various allosmias exist (or so I have been informed).

        • wjts

          What is wrong with his nose that he can’t tell that this cat is not actually a skunk? Does he have a reduced sense of smell or full on anosmia?

          I don’t know, but if I ever meet Hugh Paterson, that’s going to be the first thing I ask him.

      • David Hunt

        Fair notice. I’m stealing that line.

    • Scott Lemieux

      So wait, is the argument that because Democratic Plan A does in one instance behave (due to intervention by the SC) a little bit like Republican Plans B1 and B2, that Plan A is in fact a Republican Plan?

      Yup, pretty much.

      • Oh, that’s really just not very good at all.

        That makes less sense than venerating random water stains on a wall because they form a pattern that looks a bit like a model who posed as the Madonna in some 16th Cent. painting.

        • Scott Lemieux

          In fairness, it’s not just the Arkansas legislature. I’m sure, in determining whether the ACA is “conservative,” he would urge us to consult the Republicans who most clearly represent the policy views of American conservatives: John Chafee, Bob LaFollette, John Bingham, like that there.

          • I see what you did there.

            Also, dead people.

            No really, is this another version of Republicans are too not the real racist because Lincoln and also Jesse Helms Strom Thurmond Robert Byrd?

            Or is it more along the lines of “Once upon a time Conservative didn’t mean some pervert who divides his time between wanting to tongue bathe Donald Trump while humping an inflatable Ayn Rand doll, gnashing his teeth over the fact that the government is providing impartial aid to people in need, and obsessing over the reproductive organs and romantic lives of strangers and how he might control them. Therefore commenting on the fact that Conservative now means all of these things (and more) is unfair and in a way inaccurate, because if you jumped in a time machine and popped it into reverse for a few decades, it wouldn’t be true.”

            If so, either argument is so weak I’m surprised you didn’t fall down laughing.

            • Manny Kant

              Beware! Your invocation of Robert Byrd could summon Manju from the Lake of Trolls to prattle on about DW-Nominate scores.

            • Nathanael

              Wrong: The second argument is pretty good.

              We shouldn’t redefine the word “conservative” just because an end-timer death cult has decided to call themselves “conservative”.

              Look “conservative” up in the dictionary. Then recall the bumper sticker which says “What are conservatives conserving?”

        • joe from Lowell

          Do you seriously believe that?

          • Jordan

            Wait, you do like venerating water stains that look like old paintings of the virgin mary?

            Oh, who am I kidding. Of course you do.

          • joe from Lowell

            Not me. Name jack.

            And I hope that Jordan’s comment isn’t just a broad-brush religious slur against Catholics, but it’s sufficiently incoherent as to be impossible to suss out.

  • Your “In this discussion thread” link, first sentence, is broken.

  • dp

    Is it just me, or does arguing over adjectives seem pointless to anyone else?

    • Nope, it’s not just you.

    • Well, if the adjectives have diametrically opposed meanings, then the discussion might be worth having.

      • dp

        Why? The only adjectives worth arguing over are “good” versus “bad”; “liberal” versus “conservative” are meaningless in the grand sechem of things.

        • Jordan

          lulz.

          I think “tasty” and “gross” are GREAT adjectives to discuss in pancakes-related conversations, personally. A lot can hang on the difference!

        • “liberal” versus “conservative” are meaningless in the grand sechem of things.

          This is just

          Stunning.

          Southern strategy
          Clinton impeachment
          Iraq war
          Child labor laws
          Union busting
          War on women
          War on poverty
          Voter suppression
          Deep seated racism/sexism/homophobia
          Progressive taxation

          Nope – nothing to see here.

          Now I must go hug a squid.

          • This is why Rand Paul is the only progressive alternative in 2016.

            • Lee Rudolph

              Didn’t I hear that Ralph was pondering another run?

              • I hope so. Nader ’16 will really show the Democratic Party this time. Just like in 2000!

                • Scott Lemieux

                  Maybe there are a few hundred thousand Iranians willing to die in the name of proving Ralph Nader the greatest person in world history this time.

                • Nathanael

                  Nader was a goddamn liar in 2000.

                  Gore is frankly the only Presidential candidate I’ve been *happy* to vote for in my *entire life*. Before and after, we had sellouts.

                • Maybe there are a few hundred thousand Iranians willing to die in the name of proving Ralph Nader the greatest person in world history this time.

                  Allow me to speak for all Iranians:

                  Hell no!

          • Nathanael

            Nobody knows what “liberal” and “conservative” mean.

            You’re referring to “Democratic” and “Republican”, I think.

    • IM

      No. I actually learn a lot about the nut and bolts of american health insurance politics and recent american history.

  • Denverite

    The Arkansas plan approved by the Obama administration, conversely, requires the state to provide coverage to everyone with 138% of the federal poverty line, not just a relatively small subset of the poor.

    This +1,000,000.

    Before the ACA: In most states, you were eligible if you were REALLY poor (as in you had close to $0 income) AND were old or disabled or blind or were a kid or maybe had a dependent kid.

    After the ACA: In the states that expanded Medicaid, you are eligible if you are poor or near-poor.

    Big. Huge. Deal.

    (I’ll also note that the ACA also tries to fix one of the big pre-ACA problems with Medicaid — some doctors wouldn’t take Medicaid patients because Medicaid didn’t pay enough — by pegging Medicaid reimbursement rates to Medicare reimbursement rates. This is also big.)

    • After the ACA: In the states that expanded Medicaid, you are eligible if you are poor or near-poor.

      It allows the working poor to get coverage, which might, just might, allow them to become less poor. For example, if someone is only able to work part time or has trouble holding a job due to a chronic, untreated condition.

      Your second point deserves equal billing and I’d add to it the boosts the the law gives to primary care doctors and other providers (nurse practitioners). It’s a really exciting time in health care right now. I think in less than ten years, maybe as little as five, we’ll how we dared to call ourselves a 1st world nation before Ocare.

      • Denverite

        EXACTLY. I’m thinking about the homeless or the young working poor (waiters or barristas or whatever), which seems to be just about 90% of recent college grads not covered under their parents policies (oh, that’s right, that’s another ACA benefit). They can access non-emergent health care now! How the fuck is this not a huge progressive win?

        As for your second point, all I’ll say is that I know a lot of health care lawyers in private practice and a lot of health care company GCs. The former are constantly complaining that they have way too much work. The latter are complaining that whenever they ask the former a question, it takes a month to get a response. This is not typical of the legal industry of most other fields.

    • Yep.

      Just to break it down for folks: that means someone making minimum wage or less is now eligible for heath insurance by right in every state that signs up for it.

      The profundity of that transformation cannot be overstated.

      • Scott Lemieux

        Just like the Heritage Foundation proposal! Except for the part about about everyone making minimum wage or less being eligible for heath insurance by right.

        • Nathanael

          The Medicaid expansion is definitely a big deal, and isn’t in the Heritage Foundation plan. This is true.

          Of course, it was therefore sabotaged by Roberts.

          The rest of the ACA was left intact by Roberts because it *was* the Heritage Foundation plan.

          • Denverite

            It took more than a decade for all of the states to opt in to Medicaid in the first place.

            Don’t write the expansion off until a similar amount of time has gone by. My guess is that all states except maybe like Wyoming or whatnot will have opted in by 2020. It’s so much money. And hospitals/nursing homes/doctors have so much political clout.

            I haven’t been in on the “we’d really love to ask our state representative to talk to the governor about expanding Medicaid because there are so many potential new paying patients out there” conversation (because my state expanded). I have talked to people who have. The general consensus is not 2014, and probably not 2016. But hopefully 2017.

          • Scott Lemieux

            Of course, it was therefore sabotaged by Roberts.

            Well, yes, but a majority of states have still taken it and many more will follow.

            The rest of the ACA was left intact by Roberts because it *was* the Heritage Foundation plan.

            Wrong on multiple levels!

  • CaptBackslap

    I don’t think evaluating policies on whether they’re “progressive” or “conservative” is as useful as evaluating their effectiveness. Medicaid is already mostly a system of competing subsidized private plans, and it’s a good thing that it is. FFS (fee-for-service) Medicaid has a lot of problems that Medicaid Health Plans (MHPs) do not:

    1) Benes are completely on their own as far as finding providers. Here in Michigan, for example, adult dental is handled through FFS, and the provider situation is terrible. Even primary-care doctors can be hard to find for FFS benes in some counties.

    2) It’s much more expensive than MHPs, especially for seniors (more on them later).

    3) Benes are dependent on their caseworkers for assistance with transportation. Combined with the workloads many caseworkers have, that can cause access to care issues.

    4) Dual-eligibles (people with both Medicare and Medicaid) receive very low-quality care with FFS, and run up gigantic bills in the process of receiving it. They tend to be impoverished not only financially but socially, which means that they don’t have reliable assistance in selecting providers, making and keeping appointments, etc. And, of course, many of them have age-related cognitive or memory issues. All told, they basically get worse care than any other group but the homeless. Switching them to MHPs or a “medical home”-based system improves care and conserves scarce program resources.

    That’s not to say that MHPs are perfect, because they have issues of their own. But that they’re more market-based doesn’t automatically make them worse than the old system.

    OK, it’s Friday night, and I’m done talking about work. HTH

  • RS22

    I think the recurring issue in this debate is that one progressive group’s political orientation is focused on strengthening the role of the public sector vis a vis market institutions, per se, and another progressive group’s political orientation is focused on a more equitable distribution of societal resources. I fall in the latter camp, so this is a no-brainer, but if you fall in the former camp, I suppose you see the extension of private health insurance arrangements as some kind of burden (or at best, a mild benefit not worth the broader societal cost) rather than a boon for low-income folks.

    Our political parlance probably needs a way of distinguishing between these two orientations.

    • Malaclypse

      Or, one group prioritizes actual outcomes, while the other cares about purity.

      • Nathanael

        Obviously, Scott’s in the “purity” group then? No? If not, what the hell do you mean?

        • Malaclypse

          Well, the ACA insured several million people, which is an actual outcome, that actually happened, while you are busy complaining that it is the Heritage plan, even though it isn’t (you do realize people can look up the Heritage Plan, and that it isn’t simply a mantra, right?).

    • I think the recurring issue in this debate is that one progressive group’s political orientation is focused on strengthening the role of the public sector vis a vis market institutions, per se, and another progressive group’s political orientation is focused on a more equitable distribution of societal resources.

      Alas, no. If that were the case the dispute would still be rather bonkers (the formulations are weird; is there anyone who wants to strengthen the public sector per se? That’s a means.). But that really isn’t the case. Most sides (including Obama) have as a goal universal, effective coverage. A lot of people also have as a goal bending the cost curve. The example of other systems and the ACA is that these need not be wholly opposed.

      The problem is 1) ridiculously fanciful brute assertion that a wildly better option was there for then mere steely glint in a determined Obama’s eye, 2) transparently risible characterizations of the ACA (with amusing bizarro contentions about the Medicaid expansion), 3) an inference from 1 & 2 to Obama’s secret desire to have enacted the heritage plan, and 4) accusations that anyone who refutes (or has a giggle fit) about 1-3 is a mindless Obot hack.

      I guess it’s amusing, but I’m pretty puzzled by the degree of intellectual incompetence on display. Once Scott posted the tabular comparison, 2 was just a no hoper. And yet people defended it with brute falsities like the mandate is a) basically the whole (or the heart) of the ACA and b) this is shown by the fact that the Republicans only attacked the mandate (?!?!?)

      • Nathanael

        The real problem is that there is a large group, called the Republican Party, which is frankly opposed to people getting health care. The presence of evil whackadoodles makes the rest of the discussion… weird.

        Objectively, the ACA is the right-wing Heritage Foundation plan, and there were alternative left-wing plans. The thing is that right now, the right-wing and left-wing of our political spectrum are both within the Democratic Party, while the Republican Party is actually some kind of fanatical end-times death cult. This causes people to get very confused.

        The ACA is certainly *not* an end-times death cult policy — let me make that very clear.

        • Scott Lemieux

          Objectively, the ACA is the right-wing Heritage Foundation plan

          Objectively, you have absolutely no idea what you’re talking about.

      • RS22

        If that were the case the dispute would still be rather bonkers (the formulations are weird; is there anyone who wants to strengthen the public sector per se? That’s a means.).

        I don’t share their view, but I actually think that such a group of leftists does exist. There are lots of people on the left whose gripe with the ACA is that it is a boon to private health insurers. Perhaps another way of articulating this is as a kind of bald anti-corporatism that opposes the interests of large corporations regardless of the impact on society’s most vulnerable. Look at the current debate over GMOs as a good example. If Monsanto is for it, it must be terrible; never mind that it might help address nutritional deficiencies in various parts of the world.

        • But is it really per se? I mean, aren’t most anti corp people at least nominally against them because of their evil not because they are eg pastoral fanatics.

          I agree that some people are reflexively anti corp at least in certain industries.

  • Sly

    Because President Nixon signed OSHA into law despite attempting and failing to water it down by removing the general duty clause, we can say without any ambiguity that strict governmental oversight of workplace safety is a Republican policy priority.

  • Alex

    Ah, just looked it up. “Over 8 Romney vetoes” means “Romney issued 8 line-item vetoes for provisions like the new dental care provisions for the poor that were later overridden by the legislature,” not what people who aren’t familiar with MA legislative process would think: “the legislature passed the bill 8 times, it was vetoed in its entirety 8 times by Romney, and on the 8th time the legislature finally had the supermajority needed to pass it.”

    I don’t think “snarky” really describes the literary device used there….

  • joe from Lowell

    Is there any other field of policy, or any other historical period other than the passage of Obamacare, in which the passage of a massive federal system of subsidies, mandates on governments, mandates on employers, and mandates on the private sector, aimed at expanding access to a good the poor cannot afford on their own, would be described as conservative?

  • Nathanael

    *SIGH*

    It’s still the Heritage Foundation proposal, Scott. The ACA/Obamacare/Romneycare/Heritage Foundation health insurance plan is definitely right-wing. But then EVERYTHING is dangerously right-wing these days.

    (I don’t consider anything in recent politics “conservative” — the Republican Party hasn’t been conservative since Eisenhower retired.)

    • Malaclypse

      It’s still the Heritage Foundation proposal, Scott.

      Best not to include any actual features of either plan. Just assert your point, and maybe, just maybe, someone will admire your righteous anger.

      • Hogan

        Look, he said *SIGH*. You can’t argue with that. You can mock it, ignore it, sneer at it, point out its vacuity–the one thing you can’t do is argue with it.

        • Malaclypse

          Vacuity? From the author of this?

    • Scott Lemieux

      It’s still the Heritage Foundation proposal, Scott

      Can you point me to the massive Medicaid expansion and the requirement that mandated insurance cover routine visits in the Heritage Plan? Can you point me to where the ACA turns Medicare into a voucher system? Because if not, this is embarrassingly stupid.

    • jim, some guy in iowa

      okay, ACA doesn’t go far enough, and/or more was possible. don’t necessarily agree, but it’s a starting point

      but if people have insurance through the efforts of the government – who formerly didn’t have it at all – how is that ‘right wing/conservative’? I just don’t fuckin’ get it

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