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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.

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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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