Home / General / The Heritage Plan Was Paul Ryan’s Wet Dream And Was Nothing Like the Affordable Care Act

The Heritage Plan Was Paul Ryan’s Wet Dream And Was Nothing Like the Affordable Care Act

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ACA2

Arrrrrrrrrrrrrrgh please make it stop:

Republicans know all of this. They know it because the ACA is actually the conservative, market-based alternative to single-payer. It was essentially was the Heritage Foundation’s alternative to Hillary Clinton’s 1993 healthcare plan. It became the basis of Romneycare, the plan backed and enacted by the 2012 Republican nominee for president. It’s the Republican alternative to single-payer.

No no no no no no no no no no. This is all grossly misinforming readers of the Washington Monthly.

First of all, let’s be clear about what the Heritage Plan was. It was a plan to end Medicaid, Medicare, and most employer-based insurance and replace it all with threadbare, not-very-generously subsidized catastrophic plans. In other words, the Heritage Plan represents what the Freedom Caucus wants to do, and is radically different from the Affordable Care Act. The only significant similarly between the two plans is the penalty for not carrying insurance, but despite the outsize significance this feature took on because the neoconfederate constitutional case that was ginned up against the ACA focused on it doesn’t make the plans similar in any important way. The mandate was hardly some extraordinary innovation on the part of the Heritage Foundation — it just represents the banal fact that preventing death spirals in insurance markets requires some mix of carrots and sticks so that insurance pools are reasonably balanced.

Portraying what Paul Ryan would ideally like to do to the Affordable Care Act as what he’s seeking to destroy requires piling two tons of bullshit onto the phrase “based on.” How the shell game works is that you quickly shuffle from the Heritage Plan to two very different ones that are, unlike the Heritage Plan, unrepresentative of the views of national Republicans. The 1993 Chafee proposal is more like the ACA than the Heritage Plan, although it was still very different (no Medicaid expansion.) But more to the point it was a decoy proposed by a nominal Republican, and tells us exactly as much about Republican preferences on health care policy as Chafee’s proposal to enact a national ban on handguns tells us about Republican preferences on gun control. The health care bill signed by Mitt Romney is more like the ACA than the Heritage Plan, but again plans passed by supermajorities of Massachusetts Democrats tell us absolutely nothing about what health care policy national Republicans favor. The only internal battle within the Republican Party over what to do about the uninsured is about whether it should be “nothing” or “less than nothing.” You have to be gullible in the extreme to think that what they pretend they’re willing to support when there’s a chance Democrats might pass comprehensive health care reform is in any way meaningful.

The non-imaginary Heritage Plan is, in fact, a very useful guide to Republican health care policy goals. It explains why Paul Ryan has proposed to replace Medicare with a voucher system. It explains why he’s now trying to destroy Medicaid. It explains why Republicans initially wanted to fund their attack on the ACA by eliminating the tax deduction for employer-based insurance. (To be clear, there would be nothing wrong with this if the idea was to replace employer-based insurance with a combination of expanded public insurance and a more regulated and subsidized private market; needless to say, this has never been what Republicans have in mind.) It explains why Ryan thinks that the question of whether a plan reduces or increases the number of people without insurance is a “beauty contest.” To use the Heritage Plan to argue that Republicans really secretly wanted to pass something lie the Affordable Care Act is utterly perverse. And to call the ACA “conservative” is imagining a political spectrum that is rather radically different than the actually existing American one.

Unlike most of the people who repeat this epic howler, Atkins’s purpose doesn’t seem to be to describe the ACA as essentially worthless. But his claims are not true, and they’re not true in a very pernicious way — most importantly, it’s vastly too generous to Republicans. In the current context, it implies that TrumpCare is just a minor variation on the ACA. While it doesn’t go as far as the Heritage Plan would have, it would destroy the individual market in health insurance, make insurance worse in general, and effectively destroy Medicaid. Even when well-intended, flagrant untruths about the Heritage Plan and Republican health care policy preferences play right into Paul Ryan’s hands.

[H/T Murc]

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  • Peterr

    I have found it very helpful to keep one big thing ever-present in my mind when I follow the debate around the ACA and various alternatives: the only health that the GOP appears to be concerned about is the health of the insurance companies.

    • humanoid.panda

      Not even that: the current bill basically encourages people to stay uninsured until they get sick ,and is going to make hospitals to raise prices to compensate for all sorts of lost revenue streams. Notably, AHIP, the industry group, is opposed to the bill, and the only insurance company supportive of the bill, Anthem, needs a favor from administration.

      • humanoid.panda

        Insurance executives would be very glad with minor fixes like allowing the sale of “copper” plans, maybe some adjustment of age bands, a clamp down on special enrollments, and tax cuts. One could even argue that you could get some support from Dems from this fixes, in exchange for, say, better subsidies and elimination of the family glitch. But this plan ain’t what they want..

        • nemdam

          This is what I find so amazing about Paul Ryan’s plan. He couldn’t even get the industry to support it which you think he could do while still delivering a tax cut. The only constituency in favor of this is wealthy people.

          • Scott Lemieux

            Yeah, normally the Republicans are good at paying off their constituencies, but except for plutocrats this isn’t really the case here.

          • Vance Maverick

            Actually Anthem has weighed in somewhat vaguely in support of the bill. I believe that makes a total of one (1) public endorsement of the bill.

            • humanoid.panda

              Yeah, I mentioned this in my original comment. In related news, Anthhem needs federal approval for a merger.

            • Scott Lemieux

              You forgot Poland tanning salons!

        • los

          humanoid.panda says:

          One could even argue that you could get some support from Dems from this fixes, in exchange for, say, better…

          but Scorched Earth is modern conservative M.O.

    • Warren Terra

      the only health that the GOP appears to be concerned about is the health of the insurance companies.

      The insurance companies have been undermining the ACA in order to exert pressure and get special treatment – a practice they may deeply regret down the line – but the ACA has been great for them. Sure, they’re more regulated, they have to actually provide health care, they can only spend a reduced portion of their budget on hookers, blow, and embezzlement, and the ACA doesn’t have a special tax break for insurance company CEOs like the AHCA does – but, and this is critical, the ACA involves the insurance companies getting paid. Everyone’s got to have insurance, and a whole lot of people get help paying for it.

      The AHCA and the Republicans’ wider schemes are quite different. Sure, it will be more fun to be an insurance executive under the Republicans. It’s not all in the AHCA (because of Senate Reconciliation rules, and because of politics) but if the Republicans had their way insurers would be able to go back to the pre-ACA glory days of selling people worthless pieces of paper and calling them “insurance”. Insurers would be able to spend less of their budget on paying for medical care, and their CEOs would get a tax cut. This all sounds like a blast, if you’re an insurer (and amoral as hell). But there’s a downside: who’s going to pay for your insurance, even your cheap and worthless fraudulent “insurance”, now that it’s pricier, worse, and not getting subsidized nor its purchase mandated?

      Everyone’s seen the estimate that under the AHCA a 64-year old dude making a bad to modest income (I’ve seen anywhere from $15k to $30k, and the latter is above the median income for vast swathes of rural America) would pay roughly half their income to buy private insurance. Needless to say, they won’t pay for private insurance – they’d rather eat food, maybe even have shelter. And replacing the mandate with a weak surcharge means few healthy single people will pay premiums before their mid-40s.

      Mind you, this is more broadly generalizable. The Republicans’ economic ideas tend to be a lot of fun for amoral rich folks, while not doing much for the overall economy or even to build the institutions paying those amoral rich folks.

      • efgoldman

        the ACA involves the insurance companies getting paid. Everyone’s got to have insurance

        Which in turn means the providers actually get paid.

      • los

        Warren Terra says:

        pre-ACA glory days of selling people worthless pieces of paper and calling them “insurance”.

        as inadvertantly exposed in 2012 by a foxnews tea rant hoax,
        and as admitted very recently by Paul Ryan, though differently phrased.

  • Murc

    I feel like I deserve a hat tip for being the first one to flag this here like three days ago.

    (im so lonely)

    Unlike most of the people who repeat this epic howler, Atkins’s purpose doesn’t seem to be to describe the ACA as essentially worthless.

    Atkins was trying to draw a juxtaposition between how the ACA is portrayed (SOCIALIST DEATH PANELS BLOO ARGH!) and what it actually is, a robust expansion of the welfare that nevertheless is wedded to a number of ostensibly conservative principles, like market-based incentives, for the purpose of exposing Republican moral bankruptcy and hypocrisy.

    The problem is that he’s doing it by repeating an untruth and by comparing the ACA to something it demonstrably isn’t.

    I like Atkins but he has a number of annoying blind spots and this is one of’em. I also blame his editors (I know WaMo’s website is edited) for letting this go through.

    • Rob in CT

      And Obama has done the same* thing in the past (for the same reason).

      * well, maybe not the same, b/c I think he uses RomneyCare as his comparison and that’s not the same as The Heritage Plan. Scott can at this point remind us of the composition of the MA legislature that passed it…

      • Incontinentia Buttocks

        I think this zombie idea has endured so long in part because both proponents and opponents of the ACA have spread it. One is less likely to fact check an argument that one’s opponents are using if you can just take the whole thing and use it as an argument for one’s own side. Thus there’s been a lot of echo-chamber-y “it’s a feature!”/ “it’s a bug!” debate on the supposed Republican origins of the ACA without nearly enough scepticism about the underlying claim.

        • Scott Lemieux

          Exactly.

          • btfjd

            I may certainly be wrong, and if so correct me, but I believe the reason so many ACA supporters mentioned the Heritage plan was that it included mandates. Mandates were the issue on which Republicans focused most of their attacks, so being able to say that even the Heritage plan included mandates was seen as a good way to defend the ACA. Don’t think that worked out too well in practice, though….

        • JKTH

          I think another reason is that knowing the extent to which it’s wrong relies on knowing a lot of details that people aren’t aware of. So the fact that the ACA in a broad and incomplete sense shares traits with the Heritage plan (individual mandate and subsidies to purchase private insurance) but differs in big ways on a lot of details makes it harder for people to conceive how much different the ACA is.

        • weirdnoise

          Republicans would never in a million years say that one of their signature programs had some bad along with the good. It’s always going to be the Best Thing Ever. We’re the only side afflicted with the scourge of self-honesty.

          The ACA was flawed. Social Security was flawed. Medicare is flawed. But what we should be talking about is all the good they do. Play the fear game the way Republicans do without diluting it by saying that it will probably help you or that repeal will probably hurt you. “Someone you know will die.”

          Most people want pat answers and certainty. Nuance is confusing. Republicans know this and have exploited it thoroughly.

          • Scott Lemieux

            I’ve actually read that now is the time for Democrats to focus on selling single-payer, which is insane. You defend a program by defending it, not by arguing “it’s OK but here’s a better one.” Focus on how to improve it when you might actually control Congress again.

            • nemdam

              I should probably be slapped by pivoting to the election, but this is why I always thought Bernie going for single payer in a general election would be bad. It would basically be admitting that Obamacare sucks, but we should replace it with a plan that is supported by like 35% of the country at best once they hear it involves raising taxes and ripping away their current health insurance.

      • To clarify, it is true that the ACA is basically like so-called Romneycare. But actually that was forced on Romney by a veto-proof Democratic legislature, so made the best of it.

        • CP

          I just find it useful in the occasional argument I get into with Republicans or, worse, professional centrists obsessed with Fairness, Balance, and Bipartisanship, to use the “Romneycare” and “Heritage Foundation plan” canards when they start whining that Obama never did anything to moderate his ultra-socialist ways and compromise with conservatives.

          • Scott Lemieux

            But the ACA wasn’t a compromise with conservatives! That’s the whole problem with the argument. The much better argument is “why the fuck should Democrats compromise with sociopaths?”

            • liberalrob

              It was a compromise with conservative Democrats/Connecticut for Liebermans.

              The much better argument is spot-on.

            • Virgil E Vickers

              It doesn’t matter how sincere the Republicans were about the basic design of Romneycare etc. The important thing is the U-turn when Democrats came out in favor of it. It wasn’t the only such U-turn in the 2009 – 2011 time period. They exhibited a pattern of turning against policies or proposals whenever and solely because Obama and the Democrats came out in favor of them. Didn’t want Obama and the Democrats to get credit for anything. Obama had (and has) a deep visceral belief in compromise; it took him years to realize how hardline the GOP had become. Look at the difference between his first and second inaugurals.

    • Scott Lemieux

      I feel like I deserve a hat tip for being the first one to flag this here like three days ago.

      Done!

      The problem is that he’s doing it by repeating an untruth and by comparing the ACA to something it demonstrably isn’t.

      I can at least understand why the Bern It Down crowd repeats the Heritage Foundation lie. I don’t think Atkins was trying to argue that the ACA was worthless neoliberalism. But that just makes the argument all the more bizarre. What’s the possible angle for pretending that Republicans share Democratic goals on health care? I honestly don’t get it.

      • Incontinentia Buttocks

        I think the idea is to suggest Republican hypocrisy and knee-jerk partisanship (i.e., “they won’t even accept their own healthcare plan if Democrats propose it”)…as well as expressing the hope that mythical reasonable Republicans can be made to come to their senses to embrace what is, after all, their own plan.

        • Scott Lemieux

          OK, but Atkins doesn’t believe this shit about reasonable Republicans, does he?

          • Steve LaBonne

            Have you read much of his drivel? He’s an idiot.

          • FlipYrWhig

            Atkins genuinely believes that whatever he’s doing is pushing the Overton Window to the left, and likes badgering people about how the things Democrats support are not the leftmost edge of the possible. How one goes about _making_ Democrats support better, leftier things, that’s mostly a lot of handwaving about The Establishment.

            • weirdnoise

              Not the left edge of the possible. Smack-dab in the middle of the impossible. D.A.’s heart is certainly in the right place, but his feet are nowhere near the ground.

          • liberalrob

            It’s easier to believe in mythical “reasonable Republicans” than admit to yourself that no, at this point it’s pretty clear they really all are that crazy.

            (i.e. whistling past the graveyard of GOP rationality)

      • Murc

        What’s the possible angle for pretending that Republicans share Democratic goals on health care? I honestly don’t get it.

        The angle is pretty obvious, at least to me, because I used to kinda-sorta do it myself. (You and I have had some dustups here on the utility of it.)

        The basic idea is that there’s a decently-sized audience out there that doesn’t just automatically buy into the framing of “Republicans are full of shit and want you to die quickly if you get sick and are poor.” Because that sounds like a ridiculous caricature to a lot of folks, they assume that you are the one who is lying. Sort of like how when you show people Paul Ryan’s policy initiatives they’re like “that can’t possibly be true.”

        So you have to lead them down the garden path by saying “these are the principles and plans that the Republican Party has been espousing for quite some time regarding the provision of health care. And hey, guess what! It turns out Democratic health care plans have incorporated many of these principles and mechanisms. You would think this would achieve Republican buy-in on them, that they’d be very happy to be met halfway. And yet they are not. Why is that? Let’s use some logic to puzzle that one out.”

        Now, this has a certain amount of utility, I think, but in order to do it you have to actually compare apples to apples. The old Heritage Foundation plan can figure into these sorts of arguments, but not as “look how close we came to what they wanted and they still said no” arguments but for the later “when the rubber hits the road, this is what they actually want” arguments.

        There are also, of course, the people who don’t think the Heritage Foundation lie is a lie. But Atkins is a professional pundit, or at least semi-pro, and is expected to know better, as is the Washington Monthly, an actual media outlet and not just some blog somewhere.

        • Rob in CT

          I used to agree with you on this, but I’m increasingly convinced that Scott is right.

          • Murc

            I used to agree with you on this, but I’m increasingly convinced that Scott is right.

            Right about what? He’s openly speculating as to why Atkins, and others, whose motivation isn’t to tar the ACA as a neoliberal piece of neoliberal sell-outitude for neoliberals would deploy this howler, which suggests he doesn’t HAVE a position to be right, or wrong, about.

            • Rob in CT

              The potential value of using the argument that the ACA has significant commonalities with past (chimerical) Republican proposals to woo centrists.

        • ColBatGuano

          “Let’s use some logic to puzzle that one out.”

          And here is where I think your model falls apart.

      • Alex.S

        What’s the possible angle for pretending that Republicans share Democratic goals on health care? I honestly don’t get it.

        He saw the Republican alternative to Obamacare and realizes that it is a terrible plan that will not achieve its states goals (see Price’s promises) and that it will cause suffering that will be blamed on the Republican party.

        Therefore, he has to hype up Obamacare as the real conservative plan in an effort to sell the status quo to conservative pundits and legislators.

        • efgoldman

          in an effort to sell the status quo to conservative pundits and legislators.

          None of whom likely read Washington Monthly

          • los

            and no difference if WashingtonMonthly were more known, because RWNJ pundits are paid to not be swayed.

            (and the standard issue Top Cuck On Twitter doesn’t know what WashingtonMonthly is, so Appealing To Cuckervatives is a useless debate tool.)

    • No Longer Middle Aged Man

      Part of the problem is that we have people who are fundamentally political beat reporters trying to cover specialist issues. So not knowing anything close to the full substance of a topic — you can’t understand the ACA by reading clips from the morgue about it, even if you don’t read the actual enabling legislation you still have to read more than a few of the wonky specialist analyses of it to get beyond the superficial aspects — they cover it from the political aspect. Much the same happens when the political beat reporters, who are the stars, cover economic issues.

      Other things cited above (e.g., politically convenient to present it that way for some Democrats) also are true. But asking political reporters to talk about what the ACA actually is, as opposed to the politics of the ACA, is about as productive as expecting that reporter to talk about where Damnien Hirst fits vis-a-vis the mid-century abstract expressionists and the larger arc of 20th century modern art.

    • efgoldman

      I also blame his editors (I know WaMo’s website is edited) for letting this go through.

      As i said in your original post, it’s difficult to interpret somebody who never uses ten words if fifty will do the same job.
      And THAT’s on his editor(s)

    • catclub

      a robust expansion of the public welfare that nevertheless is wedded to a number of ostensibly conservative principles, like market-based incentives

      I will note that the ACA is NOT a one-size fits all big government solution. Those markets are different for each state.
      and so are the subsidies, depending on each state and the insurance costs within each state.

      BUT the GOP bill IS a one-size-fits-all, big government non-solution. Alaska residents will suffer the most because insurance there is MUCH more expensive than other places, but the GOP bill does not care. (Yes, this is obvious, but no one seems to bother pointing it out for a specific case.)

  • Origami Isopod

    Oh. It’s Dave “There Is No Spoon” Atkins. Nuff sed.

  • Hogan

    He’s getting roasted to a nice turn in the comments, so there’s that anyway.

  • Peterr

    It explains why Ryan thinks that the question of whether a plan reduces or increases the number of people without insurance is a “beauty contest.”

    That’s an interesting choice of words, given the comments on beauty contests made by Trump over the years:

    . . . in a 2005 appearance on Howard Stern’s show, Trump bragged about doing exactly what the women describe. “I’ll go backstage before a show, and everyone’s getting dressed and ready and everything else,” he said.

    His position as the pageant’s owner entitled him to that kind of access, Trump explained, seemingly aware that what he was doing made the women uncomfortable. “You know, no men are anywhere. And I’m allowed to go in because I’m the owner of the pageant. And therefore I’m inspecting it… Is everyone OK? You know, they’re standing there with no clothes. And you see these incredible-looking women. And so I sort of get away with things like that,” he said.

    (Billado told BuzzFeed she mentioned the incident to Trump’s daughter, Ivanka, who shrugged it off, saying, “Yeah, he does that.”)

    Here are other “highlights” from Trump’s storied history as a pageant creep. . . .

    Click through for those “highlights” at your own risk. Y

    I can just imagine Trump turning to Steve Bannon and asking “Why does Paul Ryan hate beauty contests?”

    • jim, some guy in iowa

      (sniff)

      hm. I think there’s a whiff of Complicit in the breeze

      • Hogan

        Did you mean Kompromat?

  • nemdam

    Mitt Romney deserves as much credit for passing Romneycare as Nixon does for passing the EPA.

    • Steve LaBonne

      Thank you, I was about to post something like that myself. There’s only one Republican position on health care, same one as always: if you’re not rich and get sick, they want you to die. Even the tiniest bit of credit for any Republican good intentions on health care is too much.

      • Shantanu Saha

        Well, there are the Republicans who believe that if you are not rich and get sick, you should give all of your earthly possessions to the hospitals that treat your condition, and then die. And your heirs should all be on the hook for the remaining payments. Because freedom.

    • Dilan Esper

      Nixon deserves a ton of credit for the EPA.

      Nixon was far to the left of modern Republicans. He wasn’t good in any real sense, but he did care about policy outcomes, which the current GOP doesn’t give a shit about.

      • nemdam

        The EPA passed the Senate without a single vote against it and only 15 votes against it in the House. It’s fair to say Republicans genuinely cared about the environment back then and that Nixon didn’t do anything to stop it, but he was irrelevant to the bill actually getting passed.

      • efgoldman

        Nixon deserves a ton of credit for the EPA.

        Bullshit.
        Or what nemdam said.
        He was smart enough to sign a bill that passed with veto-proof majorities. Like Mittster with Romneycare.
        Like any good politician, he was really good at following the crowd.

        • CrunchyFrog

          People also forget the context at the time the EPA was created. One long running new story throughout the 1960s was pollution. Tom Lehrer’s 1965 song “Pollution” was his most well known.

          (spoken) Time was when an American about to go abroad would be warned by his friends or the guidebooks not to drink the water. But times have changed, and now a foreigner coming to this country might be offered the following advice:

          (singing) If you visit American city,
          You will find it very pretty.
          Just two things of which you must beware:
          Don’t drink the water and don’t breathe the air!

          Pollution, pollution!
          They got smog and sewage and mud.
          Turn on your tap
          And get hot and cold running crud!

          See the halibuts and the sturgeons
          Being wiped out by detergeons.
          Fish gotta swim and birds gotta fly,
          But they don’t last long if they try.

          Pollution, pollution!
          You can use the latest toothpaste,
          And then rinse your mouth
          With industrial waste.

          Just go out for a breath of air
          And you’ll be ready for Medicare.
          The city streets are really quite a thrill –
          If the hoods don’t get you, the monoxide will.

          Pollution, pollution!
          Wear a gas mask and a veil.
          Then you can breathe,
          Long as you don’t inhale!

          Lots of things there that you can drink,
          But stay away from the kitchen sink!
          The breakfast garbage that you throw into the Bay
          They drink at lunch in San Jose.*

          So go to the city,
          See the crazy people there.
          Like lambs to the slaughter,
          They’re drinking the water
          And breathing [cough] the air!

          Basically, *everyone* agreed it was a serious health problem that affected everyone. (That, of course, is key. When a problem disproportionately affects poor people and/or minorities it ceases to be of concern to government.) It was virtually unanimous that something had to be done about it, and even so it took years to get the Environmental Protection Act together and voted on due to lobbyists fighting for their special provisions. To vote against that would have been like voting against a resolution to honor girl scouts.

          The EPA has been a great success, and in doing so the need for the EPA is no longer obvious to a short-memoried population seeped in pro-polluter propaganda. There is no way in hell Nixon supports that bill in the context of today.

          • Scott Lemieux

            And you shouldn’t assume a Republican Congress would have passed it, even if Republicans went along with once the bill’s passage was inevitable.

            • CrunchyFrog

              Right. As I recall from Dance of Legislation, a 1970 book about a 2 year effort to get a health care service bill passed in congress during that time, once passage became obvious the Senators who opposed it suddenly switched sides and it became unanimous with some ridiculous number of co-sponsors. The political context was completely different – there was no billionaire-club-backed Tea Party primarying GOPers and even conservatives had for the most part bought into the idea of social services as long as darkies didn’t get any.

              Nixon signed that bill, too, which surprised the sponsors since he had a pocket veto option given that it was an end-of-term bill. But he, too, was making the same political calculations as the rest of the GOP.

      • weirdnoise

        Nixon was far to the left of modern Republicans.

        The average congressional Republican in 1970 was far to the left of modern Republicans.

      • MyNameIsZweig

        Nixon deserves a ton of credit for the EPA.

        This is just ahistorical and dumb.

  • NewishLawyer

    Here is my theory which is possibly too grand and unified:

    1. A lot of people on the left would have preferred Medicare for all or Universal Healthcare. This is different from knowing whether it is reachable or not. But the best defenses I see of the ACA are always qualified as in “It is not perfect but it is much better than what existed before” or “I know ACA still has a lot of problems but….” IMO we don’t help ourselves with these kind of weak-tea defenses.

    2. A lot of liberals I know seem to use the “It’s the Heritage Plan” to convince their conservative friends and family to support the ACA. Somewhere along the line, we got confused ourselves.

    • Incontinentia Buttocks

      As I note upthread, the argument has been used by both proponents and opponents of the ACA, which helps explain its endurance despite its falsehood.

    • Steve LaBonne

      I’m so damn tired of the single-payer fetish. If we ever had a real prospect of something like the German system (not a giant leap from from ACA by the way) I should be upset because it’s not Medicare for All? Fuck that, I’d be jumping for joy.

      • Incontinentia Buttocks

        This argument will work a lot better when any Democrat actually proposes the German system, which is both truly universal and not single payer. But it’s also not remotely the ACA. So long as Democratic primary candidates offer a choice between supporting the ACA and supporting Medicare for All, all else being equal, I’m voting for the Medicare for All supporter. Yes, there are other ways to achieve true universality. But the ACA, though dramatically better than the status quo ante or Trumpcare, is not universal.

        • Steve LaBonne

          Single payer will never happen in this country. It wouldn’t happen in Canada or the UK if they were just starting the construction of a universal system.

          • Dilan Esper

            How did Medicare happen?

            Is Medicare buy in for 55 year olds possible?

            Is expanding the VA possible?

            There are many possible ways to get to socialized medicine. If you oppose it, oppose it, but don’t lecture the left just because they disagree with you.

            • FlipYrWhig

              How did Medicare happen?

              Kennedy got shot.

              • Joe_JP

                In an era where expansion of government was readily accepted & being against the federal government was seen as likely to mean you were blatantly racist & the Supreme Court was on their side (even conservatives like Clark and Harlan went along on some issues).

                Is universal health care etc. possible? Who is to know in the future. In 1990, various things around now (including the guy in the White House) was have seen as rather unlikely. But, things like that come in installments, with key moments involving a special amount of help such as having 60 votes in the Senate for a short period of time along with a majority in the House and a Democrat in the White House.

                • Steve LaBonne

                  I do believe it’s possible and will- someday- happen. When it does it will look like Switzerland or, if we’re lucky, Germany.

              • efgoldman

                Kennedy got shot.

                And LBJ had large and malleable majorities.

            • catclub

              Is Medicare buy in for 55 year olds possible?

              advance the eligibility year for Medicare down one year, each year. Also, all newborns are covered on Medicare. Gradual change.

            • Scott Lemieux

              How did Medicare happen?

              It cherry-picked extremely unprofitable customers who are also a politically powerful constituency, while leaving younger and healthier customers for insurance companies to profit from?

              Not only is “Medicare” not a good answer to the question of how single-payer can pass, passing Medicare makes it considerably harder to pass single-payer because it gives a large, political influential group of people nothing to gain and (from their perception) a lot to lose.

              I do think it’s possible to lower the Medicare eligibility age, but that’s a hell of a long way from single-payer.

            • I don’t disagree with this approach, although I will note that it is the very sort of ‘incrementalist’ approach derided by certain parts of the left (I’m looking at you, DeBoer!)

              Single payer would only ever be achieved through increments, although a more likely route to universal coverage is a combination of expanding Medicare coverage, private market subsidies, and a ‘public option’ .

        • Alex.S

          The key will be someone promising “Medicare for All” while also claiming that people will be able to keep their current insurance and that the overall cost will be cheaper.

          The math* doesn’t work, but whatever. As we’ve learned, it turns out that campaigning on balanced plans that add up and “work” is not important.

          * To reduce current health care costs requires getting rid of employer-provided insurance, in order to eliminate insurance-based overhead in health care provider costs. Alternatively, Medicare could be provided for everyone but at a significant increase to the budget, without reducing current costs (but will reduce future costs).

      • SatanicPanic

        This also bothers me about the left. The point should be about expanding coverage, I don’t care if we have to use private administrators. Seems like the left is being pointlessly hard-headed.

        • efgoldman

          Seems like the left is being pointlessly hard-headed.

          That’s definitional, isn’t it?

    • MyNameIsZweig

      But I think the reason we deploy these “weak tea” defenses of the ACA is because we *know* it’s not perfect, we *know* that there are people who – correctly or not – perceive themselves to have been hurt by it, and we know that ignoring these facts would damage our credibility if we were engaging in a good-faith discussion with someone about how best to move forward with health care policy.

      In other words, I don’t think that the reason we do this is because we are still disappointed that we didn’t get Medicare for All. I think it’s just in our nature to acknowledge the fact that the ACA hasn’t helped everybody equally, and then try to move on from there. Unfortunately, the people we’re arguing with have never even heard of “good faith.”

    • humanoid.panda

      IMO we don’t help ourselves with these kind of weak-tea defenses

      The problem with this is that, of course, the ACA is imperfect. Even from the purely technocratic point of view, it has a couple of flaws that would have been fixed in every other era of American politics (the family glitch is the most famous one). It’s really hard to defend something as the greatest thing ever when you know for a fact its the 1.0 version of where you want the system to be.

    • sk7326

      As Steve points out – most people do not understand that many countries with better health care situations are basically running “Obamacare on Steroids” – more robust financing, stronger regulations and price controls, public options.

      Single payer advocates are well meaning but their world-view is very narrow here. NHS (the British version) is single payer – but by many accounts hardly the best non-American version out there.

      • Scott Lemieux
        • Incontinentia Buttocks

          As I say upthread, when national Democratic candidates start supporting superior hybrid systems, I’m all on board. But currently leading Democrats support either the ACA or Medicare for All. Now is not the time to have this fight. But last year’s primaries were such a time and such a time will happen again. However much Medicare for All might be a political longshot, it’s less of a longshot than a system that nobody in American politics currently supports.

          • Both Clinton and the 2016 Democratic platform supported adding a public option to the ACA, actually.

      • Warren Terra

        The British NHS isn’t single-payer, it’s single-provider. In the context of American politics either is so outre as to make the distinction perhaps unimportant, but in a wider examination of health care systems it matters.

        • Scott Lemieux

          [Yes, correct except for that.]

  • pseudalicious

    I don’t mind this lie when it’s being used to make Republicans look bad to centrists who are moved by blatant hypocrisy. Less when it’s used to show that Obama Was The Great Capitalism-Loving Satan.

    • Rob in CT

      Unfortunately, we don’t get to pick how it’s used and when it resonates.

    • Scott Lemieux

      I don’t mind this lie when it’s being used to make Republicans look bad to centrists who are moved by blatant hypocrisy.

      Is there any evidence that it’s effective? I think this is a case where telling the truth is better politics.

      • Murc

        I think this is a case where telling the truth is better politics.

        Added bonus: you can absolutely expose Republican hypocrisy while being 100% truthful. You can even use their old Heritage plan to great effect here!

  • Joe_JP

    At some point, “Heritage” seems to be some minimal lowest common denominator (involving some sort of “mandate” and a “free market” of some sort, not single payer National Health Care or something) thing that is simply misleading to compare to ACA even though some do try to do so as a “gotcha” [with no Linda Fiorentino] to Republicans. And, following that thread, not overly useful even in that respect.

    • weirdnoise

      It is entirely inside baseball to John Q Public, and doesn’t say anything that Republican policy people (I use the term loosely) don’t already know.

  • mds

    The only remaining reason I might conceivably refer to the Heritage proposal is because this:

    the banal fact that preventing death spirals in insurance markets requires some mix of carrots and sticks so that insurance pools are reasonably balanced.

    is not actually a banal fact to a large portion of the public. If you had to pick one aspect of the ACA that draws the most venom from otherwise-reasonable people (i.e., no “death panels,” no “I had top-notch individual insurance that cost way less then Obamacare”), it’s the mandate, coupled with the mandatory coverage. You’re being forced to buy something that’s pricier because of all the extra stuff bundled with it. People don’t like that with their cable companies, and they don’t like it with their health insurance. Mandatory car insurance coverage has been around long enough, and can be minimal and crappy enough, for the comparison to be irrelevant. So my pitch is more “Even the Republican plan from the 1990’s had to include a mandate” to underscore just how banal an observation that should be.

    TL, DR: It ain’t just Paul Ryan who misunderstands how insurance works. So pointing out that Heritage used to understand it could be useful in particular situations. I would agree that harping on it whenever the ACA is brought up is misleading and unhelpful.

  • kped

    Krugman is on fire today:

    But have they really been working with CBO for months? They may have been talking, but was it about anything resembling Obamacare 0.5? Everything else about the AHCA looks slapdash, like something thrown together in a few days by people who hadn’t thought at all about what a flat tax credit and a widened age band would mean for, say, people in Alaska with its expensive insurance, or low-middle-income Trump voters in their 60s. I have no inside information, but this sure looks as if they were still dithering about the whole principle of their Obamacare replacement until at most a few weeks ago, and didn’t work with CBO because they had nothing to work with.

    In other words, maybe this looks like amateur hour because it is. Ryan isn’t a skilled politician inexplicably losing his touch, he’s a con artist who started to believe his own con; Republicans didn’t hammer out a workable plan because there is no such plan, and anyway they have no idea what that would involve.

    https://krugman.blogs.nytimes.com/2017/03/10/smart-republicans/?module=BlogPost-ReadMore&version=Blog%20Main&action=Click&contentCollection=Opinion&pgtype=Blogs&region=Body#more-40069

    • catclub

      people in Alaska with its expensive insurance,

      I use this to show the GOP came up with a one-size-(mis)fits-all
      solution, while the ACA deals with different markets differently.

  • herewegoagain3

    Its the heritage alternative framework for our individual market, after a round of democratic reconciliation (to improve coverage/subsidies), and a seperate medicaid expansion for the poor in the same bill.

    They want fries, we want twice baked: still “potatoes.” (See what i did there?)

    No i would not use this to sell it. But amongst friends…

    • Scott Lemieux

      Its the heritage alternative framework for our individual market,

      No it’s not.

      and a seperate medicaid expansion for the poor in the same bill.

      Ah, the ol’ “but the Medicaid expansion doesn’t really count as part of the ACA” routine — I think even Dilan isn’t flogging that dead antelope anymore.

      • herewegoagain3

        Yes it is. It is not single payer. It is a mandate to buy private health insurance. All you’re quibbling about is that what they wanted the government to require to be sold is different from what obamacare mandates must be included in the plan. I mean:

        Stuart Butler’s lecture describes what the Heritage’s mandate would look like:

        We would include a mandate in our proposal–not a mandate on employers, but a mandate on heads of households–to obtain at least a basic package of health insurance for themselves and their families. That would have to include, by federal law, a catastrophic provision in the form of a stop loss for a family’s total health outlays. It would have to include all members of the family, and it might also include certain very specific services, such as preventive care, well baby visits, and other items.

        So, you’re just arguing that “preventative care, well baby visits, and other items” are “threadbare” and that makes its completely different.

        I too would concentrate on the fact that obamacare is two bills put together. I don’t even think you deny this; you just obfuscate because you’re losing on the first point. It is heritage for the individual market AND SEPERATELY medicaid for the poor. You can’t use your subsidy to buy medicaid or buy into it with cash. You can’t demand a subsidy and a private plan if you’re too poor. It is two fucking bills smashed into one. And one of them is the heritage framework – and I freely and openly admit that it was modified to be better by the democrats with subsidies, more regulations, etc. But its still a fucking potato, no matter if its fried, smashed, with ketchup, etc, etc, etc.

        • “Single payer” and “the Heritage Plan” are not the only options available for national health care systems. Many countries with universal health care systems do not use single payer systems. France, Germany, and the Netherlands all use an individual mandate with multiple regulated insurers, for instance. France and Germany’s insurers are nonprofit, while Dutch insurers are for-profit. The Dutch system actually is fairly similar to the ACA in structure, aside from the ACA being designed to keep employer-provided health benefits in place.

          Your “two bills” argument makes no sense. The ACA was designed so that exchange benefits kick in when Medicaid eligibility drops out. Are you suggesting that it wouldn’t have been “two bills” if Medicaid-eligible people were allowed to opt for a subsidy on the exchanges instead? There are multiple complementary policies introduced by the ACA. Why is Medicaid expansion a separate “bill smashed” in and, say, risk corridors aren’t? Why are the mandate and exchanges and essential benefits and subsidies, etc. all one “bill” and Medicaid expansion another?

        • To summarize herewegoagain3’s argument:

          p1) The Heritage plan was a patchwork of programs and initiatives

          p2) The ACA is a patchwork of programs and initiatives

          c) Therefore, the ACA is the Heritage Plan (to all intents and purposes)

          However, as Stepped Pyramids points out, many countries offering universal coverage do so through patchworks of payment plans, many of which predate Heritage.

          I think it’s back to the drawing board for you, herewegoagain3

  • Jon_H11

    Slightly OT: Has anyone seen the new Rassmussen polls? They tend to be very biased towards Rep voters and Trump’s seen a 10 point negative swing since the Republican healthcare plan/middle finger to the poor came out:

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