Given how embarrassing attempts to create plausible counterfactual scenarios under which a significantly better health care bill was possible in 2010 tend to be (“threaten to primary senators who aren’t running for anything!”) people who start with the premise that the ACA was an unconscionable sellout and figure out the accompanying argument later have a new line of argument. Rather than trying to explain how Bayh, Nelson, Lieberman et al could have been compelled to vote for single-payer or a robust public option, this argument re-defines penny-ante reforms as superior to the ACA. Our own Dilan Esper has now adopted this argument:
Just because people repeat so often that this was the most liberal thing that could pass doesn’t mean it is true. We don’t know what else could have passed because the Democratic Party decided to try to pass THIS.
My best guess– but it is just a guess– is that much more anti-corporate (and thus superior) forms of healthcare reform plans could have passed, but they would not have been “universal”. (Obamacare isn’t universal either, but it is quasi-universal.) In other words, expanding S-CHIP, expanding Medicare, building public health clinics, etc., are all things that have passed in the past and could plausibly have continued to progress had that been the Democrats’ agenda. But it would have been incremental, not universal. I tend to think THAT course is more “liberal”, because I think expanding the reach of private insurance is a conservative outcome. But if you believe that the liberal goal is providing everyone with a product called “insurance”, rather than incrementally increasing the reach of public sector health care, then Obamacare is more “liberal”.
The idea that a series of fairly small-bore reforms would be preferable to the ACA is implausible in the extreme. Let me cite as my first witness Dilan Esper:
The point is, if the left is a necessary part of a coalition that Gore needs to win an election, he shouldn’t be picking right-wingers to be Vice President, and should generally be proposing more left wing POLICY (again, making “populist” speeches is not the same thing). An example: Gore was the first Democratic candidate since FDR to NOT campaign on national health insurance. Instead, he proposed only an expansion of S-CHIP. If you were an adult, and you were uninsured, you were screwed.
You can make all sorts of political arguments about how after Hillarycare, that’s a move that he needs to make to reassure centrist voters. Fine. But it’s also a fine reason for a leftist who thinks health insurance is a right not to vote for him.
OK, so it’s not surprising that Esper has only one principle for evaluating health care reform: if it’s proposed by a Democratic president or candidate for president it sucks. But this still doesn’t tell is which of these rationalizations was right. Obviously, he was right the first time (about whether an S-CHIP expansion is preferable to comprehensive health care reform, I mean; the idea that you should want Bush to be president because Gore didn’t propose legislation that would be DOA in any case is nutty):
- The burden on proof on someone advocating penny-ante reform instead of the ACA is huge. You’re giving up a massive, historic expansion of Medicaid and reforms that not only make private insurance significantly more accessible but transform the individual insurance market into something but a complete fraud. If you’re going to give up all that for reforms that will affect a vastly smaller number of people — and, in the case of a Medicare buy-in, affect people generally much better-off than the millions of people benefiting from the Medicaid expansion — there had better be an extremely compelling reason for why the massive short-term negative is worth it.
- And, of course, the counterfactual makes no sense whatsoever. To reiterate what I said last time, the idea that giving public insurance to a class of generally unprofitable customers is a path towards complete nationalization of the American health insurance industry (let alone a nationalization of American health care) makes absolutely no sense in theory and has proven utterly wrong in practice. Not only are we no close to single-payer or an American NHS than we were 50 years ago, but Medicare recipients were among the people most hostile to the ACA (and why not, since they have nothing to gain and can be persuaded that they have something to lose even if they aren’t Republicans who will hate any Democratic-proposed reform immediately.)
- The idea that an S-CHIP expansion could lead to an American NHS in any kind of reasonable time frame also betrays a massive ignorance of American political history (and, for that matter, comparative politics.) With the exception-that-proves the rule of abolishing slavery, American reform has always involved buying off entrenched interests. Lyndon Johnson, in extraordinarily favorable political circumstances, had to settle for cherry-picking unprofitable customers rather than doing comprehensive reform. Other high-veto-point systems otherwise more favorable to progressive politics don’t have nationalized health care either. If you extend the time horizon long enough it’s impossible to rule anything out entirely, but 1)trading a policy achievement that represents a major improvement for tens of millions of people for the magic beans of an unprecedented mode of reform is insane, and 2)in some hypothetical circumstance long after we’re all dead where nationalizing the American health industry would be viable, there’s no plausible reason why it wouldn’t be equally possible under the status quo established by the ACA.
- All of this assumes that these penny-ante reforms would have passed. If you try to do much less than the ACA and don’t even get that, the fail becomes truly epic.
- And, finally, the fact that S-CHIP expansions have passed before is self-refuting. If you can pass them in much less favorable circumstances than existed in 2009, why on earth would you squander a once-in-a-generation-or-two legislative context on trying to pass it? A Medicare or S-CHIP expansion can be added on to the ACA at least as easily as they can be added on to the status quo ante.
So, yeah, the idea that substituting an S-CHIP expansion or a few public health clinics for the ACA would be a good tradeoff for progressives is so far from defensible the world’s most powerful telescopes can’t even see it.