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The Republican Health Care Pathology

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Reihan Salam has a long Slate article explaining why Republicans generally want to repeal the ACA, conceding that have no actual alternative to the ACA with any possibility of generating consensus with the party, and…not really dealing with the implications of the latter. The article does serve one useful purpose in explaining why there’s nothing “conservative” about the ACA. The section on Paul Ryan wanting to end Medicare is particularly useful in illustrating why assertions that the ACA is “neoliberal” are so nonsensical. If the status quo ante had been single-payer, it might make sense, but in the actual context calling the ACA “neoliberal” makes about as much sense as calling the Clean Air Act or Civil Rights Act “neoliberal.”

The key to Republicans on health care lies in Salam’s assertion that “[c]onservatives tend not to be enthusiastic about redistribution.” Brian Butler has a good response, and DeLong really gets to the heart of the issue:

As I see it, there are three possibilities:

1. Poor people don’t get to go to the doctor–and die in ditches.
2. Poor people get to go to the doctor, but the doctors who don’t treat them don’t get paid and have to scramble to charge somebody else via various forms of cost-shifting.
3. The government subsidizes insurance coverage for people of modest means by raising taxes on people of less modest means.

In my view, Slate’s editors seriously fell down on the job in not requiring that Salam say whether he thinks it is better to go for (2)–imposes in-kind taxes on doctors–or (1) rather than (3). The view on the left and in the center is that (1) is a non-starter. As Margaret Thatcher said back in 1993 when she visited Washington, DC: “Of course we want to have universal health care! We aren’t barbarians!” The view on the left and in the center and on the not-insane right is that (2) is profoundly dysfunctional and would prove extraordinarily inefficient. If Salam prefers (1), he should explain why Margaret Thatcher was a squishy leftist. If Salam prefers (2), he should explain why he disagrees with every single technocrat who knows about the health-care financing system.

Exactly right. If you don’t believe that non-affluent people should simply be left to die needlessly from illnesses and injuries, you have have to believe in redistribution. The only question is whether it will be relatively efficient and equitable or grossly inefficient and inequitable. (Given that Salam implicitly favors the latter, his assertion that conservatives are “particularly skeptical about redistribution that isn’t transparent” can only be seen as black comedy.)

The other striking thing about Salam’s article is how blind all the hand-waving about “markets” is to both theoretical and empirical objections. The cliches about how markets will control health care costs seem to be unaware that Ken Arrow ever existed. And more importantly, you would think from Salam’s article that health care policy was uncharted territory, that the problems presented by the American health care system in 2009 had never been addressed anywhere. In fact, every other liberal democracy has addressed them in ways that provide universal coverage for less and often much less money per capita than the American system. The burden of proof evidently lies squarely on those who would “solve” the problems of American health care by taking us further away from systems that produce better outcomes for less money. For obvious reasons, Salam just omits the discussion entirely.

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  • That DeLong is actually even more brutal than your quotation suggests.

    And I need to bookmark that Krugman post, so instead of having that argument ever again, I can just link it. (Like the joke about the old guys telling jokes by number: “52!” “Haw, that’s a good one!”)

    • “106”

      “You know you can’t do a Scottish accent.”

  • Aimai

    I love it when Brad puts the boot in like that. But it really shouldn’t be so rare. Its not hard. These guys are either illogical or lying or both. Its not difficult to force them to acknowledge their own contradictions. Or rather: it shouldn’t be.

    • DrDick

      I think that the real problem is that very many conservatives are market fundamentalists, in a religious sense. Like other religious fundamentalists, they are impervious to data and logic and simply gloss over the contradictions. Also like religious fundamentalists, they selectively quote their sacred texts (Adam Smith, Von Mises, Hayek, Freidman, etc.) that they have not read and do not understand.

      • guthrie

        I started calling them “market worshippers” a while back. As a short summary of their apparent belief I think it does the job.

        • BruceJ

          Market Cultists is a better term. They’re just lucky that the Chicago School hasn’t recommended new Nikes and an applesauce phenobarbital entree for a pleasant trip to the Mothership.

          • guthrie

            I don’t see that it is really better, although it would be interesting to know what the word ‘cultist’ triggers in your head as opposed to the word ‘worshipper’.

        • leftwingfox

          Free Market Fundamentalists has been my go-to term for a while now too.

        • Bas-O-Matic

          I really don’t know that markets are what they worship. What they worship are low taxes. Specifically low taxes on rich people. They don’t really care about markets being efficient or government being inefficient except insofar as that serves as a reason to keep taxes low, especially for rich people.

      • Incontinentia Buttocks

        Though even for market fundamentalists there’s a question. Which of the following do they believe?

        1) The market is always just, so those who cannot afford healthcare deserve not to have healthcare.

        2) The market will, by definition, produce the best outcome, and will give everyone access to healthcare if we just deregulate it enough.

        • tsam

          The great thing about being a true believer is never having to choose.

          • Linnaeus

            Exactly. It’s either/or depending on the context.

        • Brett

          Pretty much #2. The honest ones* figure that if you just deregulated all medicine, reputation threats and non-governmental consumer advisory organizations (like consumer magazines) would eventually lead to a cheap, low-cost health care system that offered care to everyone. Sure, poor people would get inferior care and die more frequently, but In The Long Run** they’d have better care because medical care aimed at the rich would eventually become available to the poor, etc, etc.

          And as for poor people, well, Milton Friedman’s Private Charities would step in to save everyone because something, something, Gilded Age not as bad as it seemed, etc, etc. Stupid, but you can see the rationale buried in it – stuff aimed at the rich often has become available to poorer people with mass production and time, and it almost makes sense if you ignore everything that makes using health care a very constrained choice.

          * I say “honest ones” because most Republicans don’t really believe what I said. Theirs is a “I’ve got mine attitude”, whether they are well-off people with company health care, or old people on Medicare that they’ve “earned” and “paid for”.

          ** We could also call this the McMegan argument.

  • Joe_JP

    The article does serve one useful purpose in explaining why there’s nothing “conservative” about the ACA.

    I guess on some level the name game is unproductive, but I guess its use of the free market insurance market as an important part but regulating it brings to mind this:

    The answer, in my opinion, is no – there is a fundamental difference when it comes to core economic issues. It seems to me that traditional “liberals” in our current parlance are those who focus on using taxpayer money to help better society. A “progressive” are those who focus on using government power to make large institutions play by a set of rules.

    http://www.huffingtonpost.com/david-sirota/whats-the-difference-betw_b_9140.html

    I note the article has a date stamp of 12/31/1969. Anyway, the use of regulating the free market (ETA: yeah, this term is misleading, but it has some meaning, I think) with Medicare etc. added is different than let’s say just having a government led single payer. What word fits? Here? See, e.g., Krugman saying “socialism” isn’t the only solution.

    • Scott Lemieux

      I don’t really see the puzzle here. Both the subsidized exchanges and the Medicaid expansion are forms of liberalism. It only becomes an issue when you’re determined to assert that any policy that doesn’t deliver each and every magic pony you’re looking for is “neoliberal.”

      • Joe_JP

        “Neoliberal” on some level is more a mind-set as much as anything else. What is “socialist” anyway — Krugman says that isn’t necessary for a sane health plan here — if the large amount of government involvement isn’t that now?

        The “conservative” position now includes some aspects of clear “liberalism” such as many realizing you can’t just have people dying on the streets. I guess it’s a question of what words mean when goalposts change.

        • delong

          I don’t think it does: I think Salam’s “don’t like redistribution” is code for “untreated poor people die in the streets”

          • Joe_JP

            I’ll take your word for it. The analysis of his article doesn’t lead me to feel compelled to waste spend time reading it.

        • Sly

          “Neoliberal” on some level is more a mind-set as much as anything else.

          “Neoliberal” on every level is more of a useless buzzword than anything else. It’s been drained of its philosophical nuances and now just serves as a catch-all substitute for “someone or something I dislike.”

          Much like “Neocon.” Or “Hipster.”

          • tsam

            I liked the term before everyone else did.

          • Incornsyucopia

            “Neoliberal” on every level is more of a useless buzzword than anything else. It’s been drained of its philosophical nuances and now just serves as a catch-all substitute for “someone or something I dislike.”

            Much like “Neocon.” Or “Hipster.”

            This. It’s a substitute for thinking that has long outlived any usefulness it may have had.

      • liberal

        On the level of practical politics and policy reform, yes, they’re liberal, which I’m certainly willing to agree is the main issue here.

        Purely on a level of policy prescription (omitting practical considerations), however, the exchanges are certainly neoliberal. Private health insurance is neither more equitable nor more efficient than single payer. The only reason to launder the money through private concerns is to allow the latter to skim.

        Of course, the fact that the exchanges ultimately are similar to something a neoliberal would recommend doesn’t mean Obama is a neoliberal or that the effort behind the ACA was neoliberal. (Obama is pretty clearly a neoliberal for other reasons—no liberal worthy of the name would support the abomination called the TPP.)

        • gmack

          I think this gets the issue correct in some respects, but not others. The ACA clearly has some “neoliberal” aspects. It deals with health care not through single payer or government ownership (a la the British system or the VA) but through market reforms, and it continues the trend of putting more responsibility on the individual to make health care decisions. And yes, these aspects make it worse than more “liberal” or socialist alternatives (iow, I think most on this blog would agree that the ACA is a worse policy than single payer or government run health care). On the other hand, there are lots of elements of the ACA that don’t really fit what most people mean by neoliberalism at all. It relies on market regulations (neoliberalism usually is associated with deregulation), and the Medicaid expansion doesn’t fit at all. Of course, leaving all that aside, I also don’t know why this matters. I don’t much care for the ACA as policy, and yet I have come to conclude that it is a clear advance over the status quo ante and is also likely the best reform possible under the circumstances under which it was passed (certainly, it is a better policy than whatever potential replacement policy would come out of the current Congress–or those of the foreseeable future).

          • Aimai

            This seems perilously close to arguing that anything that isn’t socialism or outright communism is “neo-liberal” –what, then, is liberalism? Neo liberalism, as I understand it, is really just severe capitalism, crony capitalism, and proto fascism by another name. Surely there is some room left for classical liberal approaches to something like health care which are aimed at ameliorating the ravages of capitalism and the market without necessarily getting rid of both?

            • Denverite

              Surely there is some room left for classical liberal approaches to something like health care which are aimed at ameliorating the ravages of capitalism and the market without necessarily getting rid of both?

              Either you or I really misunderstand what “classical liberalism” is.

        • Scott Lemieux

          Purely on a level of policy prescription (omitting practical considerations), however, the exchanges are certainly neoliberal. Private health insurance is neither more equitable nor more efficient than single payer.

          But single payer is not the relevant baseline.

    • royko

      Honestly, the word that fits best is “pragmatism”.

      I mean, I can understand some value from an academic perspective in trying to classify what type of ideology the ACA best conforms to.

      But when looking at what actually happened, the ACA took the shape it did (integrating private insurance) because most people already had private insurance, and taking it away from them and messing with their benefits packages was close to politically impossible. Ideology, or even a vague notion about the role of government, didn’t really play into it (see the Tea Partiers saying “Keep the government’s hands off my Medicare!”)

      The status quo at the time constrained what was possible a lot more than how left/right/socialist/neoliberal/libertarian the country was leaning.

  • delong

    Why, thank you…

    May I say that I really feel as though I am a mild-mannered bipartisan technocrat–a stalwart of the Rubin Wing of the Democratic Party–who has fallen by some bizarre transporter malfunction into some version of the Star Trek episode “Mirror, Mirror”?

    • liberal

      …a stalwart of the Rubin Wing of the Democratic Party…

      The fact you can publicly label yourself as a member of the “Rubin” faction of anything, after the 2008 debacle, is frankly amazing.

      • delong

        You didn’t read what I wrote, did you?

        • liberal

          Yes, Brad, I read that you called yourself, fondly, a member of the Rubin wing of the Democratic Party.

          Still acting the part of the authoritarian censor over there at your blog?

        • sparks

          There are people here who have long memories of you. 10+ years. I’m one who believes Today’s Brad can easily regress to Yesterday’s Brad.

    • Rob in CT

      1. I don’t think your self-conception is really true for the most part anymore. I think you, like many of us, have been radicalized to some extent by GOP insanity.

      edit: wait, I may have misunderstood. You’re saying you are the mirror of Rubin faction-brad delong? Ah! Ok!

      2. But I will say that your old self was clearly on display when you were championing Larry Summers for Fed chair recently. UGH.

      • liberal

        Yeah, no kidding. There’s also his sickening history of plaudits directed at Greenspan.

        His apparent claim that he’s no longer a Rubinite, if I read him correctly, is laughable.

        • Rob in CT

          Shit, I used to think Greenspan knew what he was doing too. In my defense, I was a teenager…

          • liberal

            That’s a reasonable defense:

            There are two novels that can change a bookish fourteen-year old’s life: The Lord of the Rings and Atlas Shrugged. One is a childish fantasy that often engenders a lifelong obsession with its unbelievable heroes, leading to an emotionally stunted, socially crippled adulthood, unable to deal with the real world. The other, of course, involves orcs.

            The only thing in Greenspan’s defense is that he didn’t listen to all the NAIRU bullshit in the late 1990s. OTOH, that party didn’t end well, if not as badly as the party that got going in the early aughts.

            • Rob in CT

              That is one of the great quotes of the internet. I know it well, and it never fails to make me smile, with a small wince since I did in fact read & enjoy (!) Ayn Rand in my foolish youth. I was 16, bookish and an atheist. And picked on. You know how it goes. Then I grew up.

              I read Tolkein earlier, and my love of his work endures. He was a conservative, not a loon. His is by far the more realistic work. Which is amazing, considering Tolkein set out to write “high fantasy, that is purged of the gross” – meaning heroic style, no sex, no swearing, no bodily functions…

    • postmodulator

      You can say that, if we are allowed to politely point out that the past fifteen-odd years tend to suggest that the existence of the Rubin Wing was illusory and its positions proved completely untenable.

      And for the record, I say that as a long-time admirer.

      • liberal

        I liked (and like) some of his blog posts, but I pretty much stopped reading there after I saw too many cases of him censoring comments (on both the left and the right) simply because he didn’t agree with them.

        • Aimai

          Cripes if a man’s blog isn’t his castle where is?

          • witlesschum

            Your roof, your rule.

            Though I’d guess I agree with liberal more than delong about things, I’m not sure why I should be bothered by the later policing his blog comments.

          • TriforceofNature

            This is true, but you can’t pretend to be an intellectual and open to discourse in the comments and then delete what you disagree with. I mean, there are the obvious JenBobs that should be deleted (when they fail to entertain). But someone who deletes constructive comments just because he/she disagrees with them is not someone I can respect or follow. He’s free to do it, we’re free to respect him less for it.

          • DonN

            That’s true enough. But DeLong pulls comments that point out errors that can be fact checked. For example, point out that some of his positioning about Chomsky (of whom I’m not a fan) is simply wrong – with links that can be checked – he just pulls the post. I understand he owns the blog but it is worth noting how he runs it.
            DN

        • Malaclypse

          I say this as someone who has on occasion not made it through moderation over at Brad’s place: 1) JenBob is proof that lines need to be drawn. 2) Econ blogs normally have a higher-than-usual lunatic to sane commenter ratio. (“Let me tell you my theory of money and taxation. It is my theory and it is mine. Also, [insert paranoid fantasy here] prevent this theory’s obvious truth from being known.”] 3) Even if I don’t always like where Brad draws the line, I think he’s acting in good faith given the problems of 1 and 2.

          • I for one am shocked that comments along the lines of Liberal’s foregoing “what an idiotic tool you are” shtick evidently are not welcome at DeLong’s blog.

  • CP

    They’ll tell you that if governments gets out of the business altogether, kind and decent human charity will fill in the blanks, and do a better job, because reasons.

    If you point out that this only leaves the poor at the mercy of churches, businessmen and other assholes using the carrot of good health to control their behavior, they’ll say “hey, they can always go elsewhere” or “hey, I’m not going to subsidize lazy assholes who’ll blow it on whores like the government does” or “hey, if they want my money, it’s only fair that I set a few rules about how they use it, and it’s for their own good.”

    And of course that’s exactly what they want. All the bitching about the welfare state “creating a dependency” is, like so many other things with them, projection. They want the poor to be utterly dependent on the whims of the rich and powerful, as it was in the Gilded Age.

    • Pat

      You’re kind of there, but you don’t finish the thought. If the poor are utterly dependent on the whims of the rich and powerful, then certain groups will be rewarded and other groups will be punished. This fits with the vengeful Christian mindset – some (us) will be saved and some (them) will be damned.

      If all groups are supported, i.e. God loves all his children, then that is an abomination.

      I see this particular paradox as the heart and soul of the American conservative christian movement.

      • CP

        Oh, of course.

        I mean, I kind of assumed that was implied in “whims of the rich and powerful.” It means they (since that’s who they identify with) get to pick and choose between the Deserving and Undeserving. Run death panels, if you will – again, projection.

        The despicable thing about the welfare state to them is that it’s there for you regardless of whether or not you fit the High And Demanding Standards that they set for People Whom It Is Acceptable To Assist. It looks at whether or not you need the help, rather than whether or not you are worthy of the help.

        • Pat

          Exactly. But this primal emotional response flies in the face of their own theology.

          Another problem a lot of conservatives have with the welfare state is that it is currently designed to make it very hard to apply for benefits. So they wander the maze of forms and departments, unable to get help that they need. And they wonder, How do all of those people get the benefits I hear that they get? Why can’t I get them?

          This is one of the nastier aspects of state Republican administrations.

    • liberal

      Your points are completely valid, of course, but IIRC there’s actual hard empirical data that tracks the history of these things (e.g. doctors treating indigents on a charitable basis)…and the “charity will fill the gap” angle is severely wanting.

      • CP

        Not to them it’s not. Either they’ll say “but if there were flaws it must also have been because of government interference” (heck, there’s a whole thing about how the excesses of the robber baron era are all the fault of the government, because of corporate-government collusion)… Or they’ll tell you that that wasn’t “wanting:” it was performing exactly as it should. Those were the days when a man had to be ready to work hard and be righteous to earn his keep, and those lazy people who just loafed around on the couch or those evil sinful people who wouldn’t repent and come back to the church in all humility received their just desserts.

        • liberal

          The funny thing is that they have it completely reversed. By and large, the people who are making money for nothing are the rich. As John Stuart Mill pointed out over a century ago, landowners get wealthy in their sleep for doing absolutely nothing.

          Hence the usual shibboleth about “only property owners should vote” has it exactly backwards—owning land in the absence of high ad valorem taxes is a vice, not a virtue.

          Sadly, most liberals/leftists don’t seem to get this either.

        • Hogan

          “but if there were flaws it must also have been because of government interference”

          Need more doctors? Stop forcing them to go to medical school and apply for licenses and certification. You’ll have doctors out the wazoo.

          • Do this:

            Stop forcing them to go to medical school and apply for licenses and certification.

            and the wazoo may become a recognized medical term.

      • guthrie

        I’ve got some old books on my shelves from the good old days, back in the gilded age, making the case for proper health care services instead of the horrendous sort that existed back then. It’s rather worrying that we have to fight the old battles again.

        • Pat

          Well, some battles get settled, and some flare up anew. I think that we win them one or two at a time. But we do win. There is progress.

    • Rob in CT

      Right. Like everything else, it’s about power and control. Conservatives prefer private power and hierarchy. “Freedom” means being able to wield that power without the gummint bothering you.

      • CP

        I’ve said this before, but a lot of the conservative worldview is immediately familiar if you go back to old Europe and the conflict between the monarchy and the local aristocrats. The latter thought the king should exist basically for big picture stuff like fighting wars, but should otherwise stay the hell out of their little fiefdoms and let them continue to rule them as they saw fit.

        Nowadays, of course, we don’t have a king, we’ve got an elected government, but damn if we don’t still have the feudal assholes.

        • DrS

          damn if we don’t still have the feudal assholes.

          As anyone who has seen the documentary film on tai chi, Roadhouse could tell you

  • tsam

    The cliches about how markets will control health care costs seem to be unaware that Ken Arrow ever existed.

    And are entirely ignorant of the health care business model. Health care isn’t a widget.

    But conservative also know damn well that their objections to the ACA are completely unfounded and rooted in NOTHING more than sticking it to the poor, who they feel don’t deserve to be healthy, educated, nourished and sheltered.

    tldr: Conservatives are just lying assholes entirely devoid of conscience or empathy.

    • Linnaeus

      But conservative also know damn well that their objections to the ACA are completely unfounded and rooted in NOTHING more than sticking it to the poor, who they feel don’t deserve to be healthy, educated, nourished and sheltered.

      In the same discussion that I mention in my comment below, I also argued that, while flawed, the ACA does help to expand access to health care by expanding health insurance coverage. My interlocutor and another one proceeded to list the bad things they expect to result (fewer doctors, worse health outcomes, etc.) and then said that “a health care card paid for by others does not guarantee access to health care”.

      Now, there may be some truth to the point about guaranteed access, since you might be in a narrow network, you may have a problem with deductibles, etc. But it seems to me – and maybe I’m just really wrong here – that in a system in which health care access is financed through private insurance (for the most part), not having coverage excludes you from finding care.

      ETA: I forgot to comment on the part that I took notice of, which was the “paid for by others” bit. Both commenters made a point of saying that, and I suspect that was the real crux of their argument.

      • NonyNony

        Anyone who argues that “a health care paid for by others does not guarantee access to health care” does not know how insurance actually works.

        • tsam

          Why bother with the facts though? If Moops invade Spain and Columbus discovered America then health care is unpossible so just get a better job.

        • Linnaeus

          That thought did occur to me in an esprit de l’escalier kind of way, but I figured it wasn’t worth it to go back.

    • postmodulator

      Nothing’s a damn widget. That’s what “widget” means.

      I can’t think of another field where a C in the 101-level course makes you feel like you can shout down the people with PhDs in the same topic.

      • witlesschum

        Um, all of them?

        Let’s go to live to Rand Paul, explaining the Civil Rights Movement to some students at Howard.

      • guthrie

        Climate science.

        Basically it isn’t so much that they have some learning in the topic as that ideology takes over, and the authoritarian mindset is especially vulnerable to the ideology removing anything ‘real’ from the playing field.

      • NonyNony

        I can’t think of another field where a C in the 101-level course makes you feel like you can shout down the people with PhDs in the same topic.

        Computer science. And the C isn’t mandatory – a D is good enough if your professor was clearly an idiot who didn’t understand the nuances of programming like you do.

      • tsam

        I’ve heard health care referred to as “widgets” in ill-fated, misguided attempts to reduce it to a simple supply/demand chain that one learns in Macro Econ 101. These were so called experts on NPR in some cases (meaning some fucking asshole from a think tank or lobbying group).

        We’re all guilty of thinking we know more about things than we actually do–the critical difference is being able to form your opinions and thoughts around actual facts, and not being so goddamn lazy that you refuse to go out and get facts, or accept facts that come right out of the asses of pundits.

      • Nothing’s a widget, but things can be widgetlike or unwidgetlike. Manufactured, durable goods are widgetlike, the more uniform the better. Personalized services which are highly dependent on skilled labor and capital, like medicine, are about as unwidgetlike as it gets.

    • Sly

      But conservative also know damn well that their objections to the ACA are completely unfounded and rooted in NOTHING more than sticking it to the poor, who they feel don’t deserve to be healthy, educated, nourished and sheltered.

      I always go back to what my father said about Medicare: “The worst thing about it is that you can own your own business and still end up dying in the same hospital room as someone who dug ditches their entire life.”

      Which is a horrible thing… for the ditch-digger. Who wants to spend their last remaining days on Earth in the same room as some spiteful asshole? Especially if those last remaining days are capping off a life spent digging ditches.

      • tsam

        Yeah, that’s just a terrifying thought. What if the ditch digger is BLACK? Or gay?

  • Linnaeus

    In fact, every other liberal democracy has addressed them in ways that provide universal coverage for less and often much less money per capita than the American system.

    I pointed this out in a Facebook discussion about Grubergate and was informed by another commenter that that meant that I wanted intractable double-digit unemployment and a failing society due to falling birth rates.

    • rea

      intractable double-digit employment

      Jeez, I sure hope we can manage to keep employment in double digits . . .

      • postmodulator

        While I appreciate the edit function, it somewhat spoiled the joke.

      • Linnaeus

        Sorry, that was a typo. Fixed.

        Although I looked up unemployment figures on some peer industrialized nations, and although France’s unemployment is around 10%, Germany’s is at 4.9%, the UK’s is around 6%, Canada’s is 6.5%, Sweden’s is at 8%, Norway’s is around 5-6%, and Japan’s is below 4%. Some of those figures could be better, but those nations are hardly collapsing.

        • CrunchyFrog

          And they count unemployment differently than is done in the U.S. – that is, more honestly. As in # fully employed / workforce.

          But to a conservative Europe is always in an economic crisis due to socialism, the earth is always cooling, the economy is always better under GOP rule and the deficit always higher under Democrats. Fuck facts, those are axioms.

        • Redwood Rhiadra

          Also a lot of the countries with “double-digit unemployment” (e.g. France, Spain) use a more expansive definition of unemployment than the number usually reported in the U.S.

          ETA – or what CrunchyFrog said…

  • Murc

    If the status quo ante had been single-payer, it might make sense, but in the actual context calling the ACA “neoliberal” makes about as much sense as calling the Clean Air Act or Civil Rights Act “neoliberal.”

    My understanding of neoliberalism is that it is a philosophy of eschewing direct government intervention but, instead, using market-based solutions, incentives and disincentives to achieve liberal ends.

    And in that context, the ACA is assuredly neoliberal, is it not? It attempts a variety of market-based solutions with as light a government hand as possible. In fact, I seem to recall that minimizing direct government intervention in the ACA was a necessary precondition of getting the corporate whore wing of the Democratic Party to sign onto it.

    Or am I operating under a mistaken definition of neoliberalism?

    As Margaret Thatcher said back in 1993 when she visited Washington, DC: “Of course we want to have universal health care! We aren’t barbarians!”

    Isn’t it widely believed that Thatcher was basically just straight-up lying about this?

    • Rob in CT

      I think it shows how important it is to get programs passed into law even if they’re imperfect (e.g., the ACA). They do become a baseline. Brits complain about the NHS (and rightly so – it’s a democracy and no program is perfect), but the idea of repealing it is simply beyond the Pale. Thatcher may indeed have privately wished to gut it, but she was not stupid so she didn’t dare say it out loud.

      • Linnaeus

        This is one reason why I think the ACA is a game changer – there’s a reason why Republicans say “repeal and replace”. The ACA isn’t polling well now, but most Americans don’t want it gone, either. They’d like to see it improved. Politically astute Republicans know that expectations have been raised and that they have to at least appear as if they don’t want to return to the status quo ante.

        • Pat

          You should have told that to the guy with the lawsuit about subsidies!

      • Murc

        Brits complain about the NHS (and rightly so – it’s a democracy and no program is perfect), but the idea of repealing it is simply beyond the Pale.

        It really isn’t. The Cameron government has made an excellent start on doing just that, and if they make it back in next year the NHS in Britain will be a thing of the past by 2020.

        Oh, there’ll still be something called the NHS. It will, however, bear as much resemblance to the past incarnation as Paul Ryan’s Medicare would to actual Medicare.

        • Rob in CT

          Fuck, it’s gotten that bad?

        • Lee Rudolph

          Hey, it’ll still be “National”. One out of three ain’t bad!

          • Denverite

            Murc exaggerates a bit. In October Cameron pledged not to cut NHS spending during 2015-20.

            I’ve had positive experience with the NHS in my limited interaction with it (kid needing stitches at the emergency room).

            • Murc

              In October Cameron pledged not to cut NHS spending during 2015-20.

              That promise is worth astonishingly little, and there’s also the fact that he didn’t specify “in real pounds.” Holding NHS spending flat in nominal pounds for five years, for example, would be a huge cut.

              That said, the Cameron Government hasn’t been going directly at the NHS, which would be politically unwise. What they’ve been doing is undermining it, privatizing services wherever possible and making changes and reforms deliberately intended to make it function less well.

              Really, the Cameron Government is one of the three most revolutionary government in postwar Britain. (The other two being 1945 and 1979.) It’s just doing it in a very quiet way. Cameron is too smart to take a direct run at the welfare state, but is instead trying to kill it by inches and behind the scenes. It is actually kind of amazing. He also might manage to kill the British civil service (replacing it entirely with private contractors except at the very top end) which is kind of impressive; the British civil service has always seemed rather unstoppable.

              • sibusisodan

                I wish you weren’t so correct on all this.

                The Tories have played a blinder in the last few years, using a cover of austerity to quietly reshape quite a lot of the social contract. They even managed to privatise the Royal Mail this summer, with little fanfare.

                Prior to 2010 Cameron promised ‘no top down reorganisation of the NHS’ and then proceeded to do just that. So take those spending commitments with a little salt…

                • They even managed to privatise the Royal Mail this summer, with little fanfare.

                  Say fucking what?!

                • Murc

                  It was the Royal Mail privatization which really got my attention. Aside from the delicious irony of the name, it was pretty jaw-dropping.

                  We really need to get Brockington all up in here again on a regular basis, as I’m sure he has a better grasp of what’s happening across the pond than I do.

                • sibusisodan

                  Bijan, yup. Sold it off pretty cheaply without fanfare.

                  I’m kinda surprised how blase about the whole thing I am. When I stop to think that the Tories have just accomplished a policy goal Republicans would give their eye teeth for, and that this is just the sweet course on top of what they’ve wrought to welfare and health…

                  But then they’ve also legalised gay marriage and are about to lose a second mp to ukip. They’re this bizarre mix of Machiavellian incompetents.

                • That…I…crap.

              • Brett

                He also might manage to kill the British civil service (replacing it entirely with private contractors except at the very top end) which is kind of impressive; the British civil service has always seemed rather unstoppable.

                Now that is terrible news. Single-payer systems where the government is only the payer of health care (like France, Canada, and German) work fine, but contracting out government services to private providers rarely saves you money while improving quality. Just look at the US – one of the biggest reasons why our infrastructure construction is so incredibly expensive is because so much of the planning is farmed out to politically connected consultants who have little incentive to get costs down.

        • JKTH

          Oh, there’ll still be something called the NHS. It will, however, bear as much resemblance to the past incarnation as Paul Ryan’s Medicare would to actual Medicare.

          So saying that Cameron would end the NHS as we know it would be the Super-Duper-Uncivil Lie of the Century?

          • Rob in CT

            Four pinocchios!

        • “It really isn’t. The Cameron government has made an excellent start on doing just that, and if they make it back in next year the NHS in Britain will be a thing of the past by 2020.”

          Couldn’t, hypothetically, Nick Clegg and the rest of the LibDems simply refuse to support a coalition government that was planning on gutting the NHS? Isn’t that what a vast majority of their supporters would prefer? Does anyone have any reason to ever vote for their party again at this point? Does No Labels have any plans to expand across the Atlantic?

          • Scott Lemieux

            Third party politics cannot fail, it can only be failed.

        • Brett

          It’s definitely changing, and not necessarily in a good way. The Conservatives seem to be trying to turn it into a system where the government would only be a payer for health care, contracting with privately-owned health care providers for service.

          There’s nothing wrong with such a set-up (Great Britain’s actually rare among rich countries with universal health care in having such a heavily socialized supply side of medicine), but it will likely raise costs and not lead to significantly better outcomes in the process. Great Britain has solid care and one of the cheapest per capita systems in the OECD.

    • Joe_JP

      with as light a government hand as possible

      Sounds like more a tendency than a hard/fast rule … “neoliberal” is one of those terms that seem a bit plastic to me anyways. Those who want direct government involvement as a rule to me sounds “socialist” more than “liberal” in certain ways. The word “socialist” being tossed at people as an epithet doesn’t cause me as much horror as those doing the throwing desire though.

      • Pat

        I think someone invented the word “neoliberal” so that there was a left-side thing to compare to the “neocons.” It’s a muddy-the-waters kind of thing.

    • gmack

      See my comment above. Shorter: Sure, there are some parts of the ACA that could accurately be described as “neoliberal.” But not all parts (the Medicaid expansion, the efforts on regulating the insurance market). And I’m not sure why it matters to whether folks on the left should support the policy.

    • My understanding of neoliberalism is that it is a philosophy of eschewing direct government intervention but, instead, using market-based solutions, incentives and disincentives to achieve liberal ends.

      Let’s accept that.

      And in that context, the ACA is assuredly neoliberal, is it not? It attempts a variety of market-based solutions with as light a government hand as possible. In fact, I seem to recall that minimizing direct government intervention in the ACA was a necessary precondition of getting the corporate whore wing of the Democratic Party to sign onto it.

      This isn’t so clear to me.

      Medicaid expansion seems not neoliberal (although much is left to the states so it can be inflected that way.)

      Guaranteed issue, the mandate, etc. seem pretty heavy regulations.

      Minimal care levels, loss ratios, and no copay preventative services also seem pretty liberal.

      The exchanges involve choice and market like mechanisms but in a heavily regulated and subsidized context.

      Employer based insurance seems more neoliberal, but that’s not what the ACA introduced.

      • Rob in CT

        Right.

        It has neoliberal elements when compared to the NHS. The status quo ante in the United States was not the NHS.

        All is relative.

        • I think I agree with this and yet I feel it is wrong. Hmm.

          The post ACA US Health Care system is less liberal/socialized or regulated and more privatized than the NHS, but also than (I believe) the German or French system. It’s getting closer to those though.

          The ACA itself consists almost entirely of liberalizing mechanisms. Thus, to the degree that it fails to liberalise an aspect of US Health Care, it does so because it didn’t change something. Some proposed liberalising changes were shot down or otherwise prevented or deemed unworkable.

          (Sorry, just needed to work it out ;))

    • Scott Lemieux

      And in that context, the ACA is assuredly neoliberal, is it not?

      No, unless you think the Civil Rights Act and the Clean Air Act are “neoliberal.” Substantially increasing both regulation and government programs is just liberal, not neoliberal.

      It attempts a variety of market-based solutions with as light a government hand as possible.

      This simply isn’t true. If you want to see “as light a hand as possible,” check out (say) the Heritage Plan.

      Isn’t it widely believed that Thatcher was basically just straight-up lying about this?

      I dunno, but she had majorities in a Westminster system and didn’t abolish the NHS.

      • Murc

        This simply isn’t true. If you want to see “as light a hand as possible,” check out (say) the Heritage Plan.

        Allow me to clarify; “as light a hand as possible while still consistent with expanding and improving care.”

        The Heritage plan had a lighter hand but didn’t actually do anything, whereas from what I remember of the ACA’s passage, it was contingent on assuring a lot of Democratic Senators that it would keep government intervention to the lowest possible level. The reason it’s such a kludged-together half-a-loaf is because a lot of Democrats are, bafflingly, committed to low levels of government intervention as a matter of principle.

        I dunno, but she had majorities in a Westminster system and didn’t abolish the NHS.

        Except the quote in question was about the policy preferences of the Tories in general and Thatcher in particular, not about what they actually did.

        Example: I have no doubt the Republicans would love to murder Social Security. Many of them say the opposite of this and also vote the opposite of this. That doesn’t make their actual preferences less true or less relevant, it just means they haven’t yet figured out a way of doing this without committing political suicide.

        • Scott Lemieux

          it was contingent on assuring a lot of Democratic Senators that it would keep government intervention to the lowest possible level.

          Again, I don’t see any possible meaning of “lowest possible level” for which this could be true. The Medicaid expansion in and of itself falsifies this, and any random Republican plan will have a lighter regulatory hand the guaranteed issue/subsidy/minimum coverage/mandate stool that could nominally expand coverage. Conservative Democrats had to be appeased by making the markets less regulated than they otherwise might have been, but that’s a very different argument.

          • Murc

            Conservative Democrats had to be appeased by making the markets less regulated than they otherwise might have been, but that’s a very different argument.

            How so?

            There were/are a lot of conservative Democrats who have nominally liberal goals but don’t really want that pesky government to actually intervene into their beloved markets directly. Hence, they will grumblingly get on board when it appears there is no actual alternative to market intervention, but will strive mightily to keep that intervention to a minimum consistent with their principles.

            • Scott Lemieux

              There were/are a lot of conservative Democrats who have nominally liberal goals but don’t really want that pesky government to actually intervene into their beloved markets directly.

              Well, if so, they did a really bad job, because every core element of the ACA substantially increases government intervention.

    • Ronan

      Neo liberalism is a pretty slippery term. Perhaps it’s better to look at what it does, rather than what it’s meant to do.
      This seems a convincing explanation to my eyes:

      “neoliberalism, despite its claims, is effectively “devoted to the dominance of public life by the giant corporation.” What neo-liberals, and some leftists, see as a conflict between the market and the state is in fact an argument over how the two should relate to each other. Neoliberals are not pushing for free markets so much as a certain style of politics, which masquerades as a commitment to free markets, independent of politics, but in fact is an unhealthy hybridization of the two. To the extent that politics pervades markets, and markets pervades politics, both suffer.”

      http://crookedtimber.org/2011/09/26/colin-crouch-the-strange-non-death-of-neo-liberalism/

      (i dont know how this applies here though)

    • Brett

      Or am I operating under a mistaken definition of neoliberalism?

      I think the ACA is more an example of Corporatism rather than Neoliberalism. There’s a rich history of that in the US, using regulatory mandates and rules to get companies to provide certain services (health care, unemployment insurance, etc) in lieu of simply providing those directly from the government.

      Neoliberalism would be something more like a voucher program for health care, such as the periodic Republican talking point of abolishing the tax exemption for companies and giving people a tax credit of X amounts of dollars for buying health insurance.

  • Matt

    The right prefers (2), but not for *policy* reasons. They prefer the old system where being poor and being sick meant endless BEGGING to have bills you couldn’t repay in a hundred years “negotiated” to a merely life-wrecking scale. They are furious that the poor might not get punished quite as hard for being sick while poor.

    Of course, they can’t actually SAY this out loud – bad for electoral results, at least while people who don’t own property can still vote – so there’s a never-ending stream of bad-faith argument to dance around the issue…

  • Derelict

    I wouldn’t be so sure that Republicans DON’T want the poor simply dying in ditches. There is much about conservative that relies on and thrives from desperation.

    People afraid of ending up poor and dying in a ditch are willing to work in the worst possible jobs for the lowest possible pay. Fear of joblessness keeps them under control.

    People who are out of work will happily cut the throats of the currently employed. This, too, keeps the masses under control.

    And, of course, people who are fearful and desperate tend to turn to strong authoritarian types who wield simple nostrums to cure their ills, and who can point to some enemy as the source of those ills. “More free markets! Less immigration and liberals!”

    • tsam

      That’s right–they really believe that faced with the fear of dying in a ditch, people will be suddenly, magically able to change those circumstances.

    • Linnaeus

      People afraid of ending up poor and dying in a ditch are willing to work in the worst possible jobs for the lowest possible pay. Fear of joblessness keeps them under control.

      I recall somewhere that David Frum was pretty explicit about this. The risk people bear in capitalist economies “disciplines them and teaches them self-control.”

      • tsam

        Like Jamie Dimon and Bernie Madoff. Yeah. Discipline and self control.

    • StuckinOz

      Yeah, I used to think nobody was willing to have people just dying from lack of medical care, until I read about hospitals in Jim Crow states. Black people were regularly turned away from whites-only emergency rooms and left to die in the parking lot. That wasn’t very long ago at all.

  • Thrax

    To echo and amplify one of Brad’s points: Salam claims that conservatives oppose the ACA because they “tend not to be enthusiastic about redistribution,” because of the “soaring cost of health entitlements,” and because they want “market-based health reform that will be cheaper, less coercive, and less prescriptive.” Which of course is why we’ve now seen three straight campaigns full of right-wing ads screaming about how Obama cut Medicare spending. Yes, it’s all about conservative principles.

    • Scott Lemieux

      Not only that, Salam complains about Medicare spending cuts in the same paragraph he talks about how much he hates redistribution.

    • Salam claims that conservatives oppose the ACA because they “tend not to be enthusiastic about redistribution,”

      Salam, of course, is full of it here. Conservatives are great fans of redistribution; it just depends on the direction in which the wealth is redistributed.

  • joe from Lowell

    The other striking thing about Salam’s article is how blind all the hand-waving about “markets” is to both theoretical and empirical objections. The cliches about how markets will control health care costs seem to be unaware that Ken Arrow ever existed.

    Look, Doctor, if you can’t set this fractured femur for $1250, I’ll walk right out of here. I swear to God I will.

    • Brett

      But see, you can just leave a false name and it’s free to use the emergency room!

  • burnspbesq

    And Ryan is about to become Chair of the House Ways and Means Committee.

    You may think this implausible in the extreme, but before too long you will all be saying “Gee, I miss Dave Camp.”

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