Home / General / The Heritage Plan Was A Plan For War on Medicaid, Not a Serious Plan For Universal Coverage

The Heritage Plan Was A Plan For War on Medicaid, Not a Serious Plan For Universal Coverage

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I am, needless to say, a huge admirer of Paul Krugman. But I genuinely can’t understand why he keeps making this false and deeply pernicious argument:

Every once in a while people make the point that much of what eventually became Obamacare came from, of all places, the Heritage Foundation – that is, the ACA is basically what conservatives used to advocate on health care. So I recently reread Stuart Butler’s 1989 Heritage Foundation lecture, “Assuring Affordable Health Care For All Americans” – hmm, where have I seen similar language? — to see how true that is; and the answer is, it really is pretty much true.

First of all, this wasn’t just one guy at Heritage writing: Butler referred to his proposal as “the Heritage plan”, referring to a monograph that lays it out and does indeed present it as the institution’s policy, not just his opinion.

Second, while the Heritage plan wasn’t exactly the same as ObamaRomneycare, it was pretty close. Like the ACA, it imposed a mandate requiring that everyone buy an acceptable level of coverage. Also like the ACA, it proposed subsidies to make sure that everyone could in fact afford that coverage. That’s two legs of the three-legged stool.

[…]

Overall, what’s striking about the Heritage plan is that it’s not notably more conservative than what Obama actually implemented: a bit less regulation, a substantial amount of additional spending. If Obamacare is an extreme leftist measure, as so many Republicans claim, the Heritage Foundation in the 1980s was a leftist institution.

The claim that that the Heritage plan is “not notably more conservative than what Obama actually implemented” is just flatly false. The plans are radically different, and indeed the Heritage Plan has far more in common with the AHCA and BCRA than the ACA. We’ve been through this before, but to summarize again:

  • The ACA contained a historic Medicaid expansion that has led to millions of poor people receiving health insurance, and would have insured many more without the unholy alliance between the Supreme Court and sociopathic Republican public officials. The Heritage Plan wanted to replace Medicaid with bad catastrophic insurance. In and of itself, this difference renders claims that the ACA was essentially similar to the Heritage Plan false.
  • The ACA preserved Medicare and employer-provided insurance. The Heritage Plan would have eliminated them, requiring everyone to buy insurance on the individual market. Again, in and of itself this is a difference that renders assertions that the plans are essentially similar false.
  • But even if we just consider the exchanges, the comparison fails. It is true that there is a superficial structural similarity, but this just reflects the self-evident truths that 1)insurance not provided by the public has to be provided by markets and 2)health insurance markets don’t work if healthy people don’t have incentives to maintain coverage. (The Heritage Foundation hardly holds a patent on these banal observations.) But the regulatory differences between the Heritage exchanges and the ACA’s exchanges are far from minor. The essential benefits requirements of the ACA required insurers to offer comprehensive insurance to sell on the exchanges. The Heritage Plan not only did not have such requirements, it was designed to incentivize the purchase of catastrophic insurance, because its architects wanted most healthcare expenses to be paid out of pocket.
  • The differences between the two plans are greater in sum than in comparisons of individual parts (which are massive in themselves.) The difference between giving people tax credits to buy catastrophic insurance is substantial enough under the ACA’s structure, where the individual market is there to mop up the minority of people who aren’t covered by employers, Medicare, or Medicaid. Under the Heritage structure, where everybody is buying insurance from the individual market, the differences between the regulatory structures of the exchanges is hugely important.
  • It is true that the ACA is largely similar to the plan passed by veto-proof supermajorities of Massachusetts Democrats. But this is because the plan is nothing like the proposal put forward by Stuart Butler and Heritage in 1989.

I understand why people on the left who hate the Democratic Party and are emotionally committed to minimizing the difference between the Republicans and Democrats make this false argument. But Krugman strongly supports the ACA, and he was one of the first national pundits to recognize the Republican Party for what it is. I really don’t get it.

But I do want to emphasize again that this argument is not merely false, but politically toxic. It plays into the hands of hucksters like Avik Roy, who assert that of course conservatives want to cover everyone, but they just want to use markets. But what conservatives really want is for Congress to bring them the heads of Medicaid and Medicare, and if a Republican proposal inflicts major damage on one or the other, it turns out that they can live with Congress doing little or nothing to help poor people by private insurance. The Heritage Plan is much more accurately viewed as a plan to destroy all public insurance than a serious plan for universal coverage. And erasing the Medicaid expansion from the ACA, which Krugman’s analysis does, helps people like John Cornyn, whose speech before the vote on the HCFA attacked the ACA for leaving many poor Texans uninsured, hoping that many people wouldn’t know that this was the case because Texas turned down the Medicaid expansion.

In short, the claim that the ACA is similar to the Heritage Plan (and the implicit claim that the ACA is the policy outcome that conservatives have generally favored) is both demonstrably false and extremely damaging politically. I really wish Krugman — again, an otherwise invaluable voice — would stop making it.

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  • petesh

    http://delong.typepad.com/sdj/2011/10/1-paul-krugman-is-right-2-if-you-think-paul-krugman-is-wrong-refer-to-1.html

    That was in ref to the (lack of) stimulus, but as a general rule it’s worth considering

    • stepped pyramids

      He really just is wrong here:

      Where the plan differed was in the handling of pre-existing conditions. Butler opposed community rating, viewing it as an indirect tax on the healthy – but called instead for big subsidized high-risk pools to cover those private insurers would otherwise shun.

      The actual plan on paper kind of hand-waves the pools (and other replacement programs; there’s a suggested eldercare program to replace Medicaid’s nursing home coverage that boils down to “make the states pay for it somehow”). It’s not a specific enough plan to quote any numbers. Krugman says the pools would be “big” but that’s based on the assumption that the plan was intended to actually work sufficiently. The Butler plan also lacks guaranteed issue and essential benefits — it even calls for eliminating state laws mandating essential benefits! Those are big differences he just ignores.

      (1) The Heritage plan would have required bigger, not smaller, government spending; that is, on-budget outlays would have been larger. (2) The piece of the ACA Heritage didn’t want was the part that’s actually most popular with the public.

      Since the Heritage plan doesn’t really deal with actual numbers, I question how he got to (1). In particular, the plan eliminates the tax deduction for employer-provided health coverage, which is the single largest tax expenditure in the federal budget. The plan goes out of its way to argue that employers will replace their insurance benefits with salary raises — it even suggests (deceptively, I think) that a federal law could require such raises in the wake of a benefit being withdrawn. The plan also cuts Medicare and Medicaid.

      I’m very skeptical that such a plan would result in subsidies so generous as to spend the huge savings from slashing two of the government’s three largest social insurance policies and its largest tax expenditure, to say the least. Nor that Heritage would ever want the subsidies to be that generous.

      • Rob in CT

        The actual plan on paper kind of hand-waves the pools (and other replacement programs; there’s a suggested eldercare program to replace Medicaid’s nursing home coverage that boils down to “make the states pay for it somehow”). It’s not a specific enough plan to quote any numbers. Krugman says the pools would be “big” but that’s based on the assumption that the plan was intended to actually work sufficiently.

        In other words, if liberals got to fill in the blanks, the Heritage plan kinda-sorta in certain ways might’ve looked like RomneyCare/the ACA (if we ignore Medicaid expansion).

        • petesh

          Yes. There is no point in being blinded by (well-justified) hate for Heritage.

          • Rob in CT

            You know I’m agreeing with Scott and Stepped, right?

            • petesh

              Er, no. You are suggesting that if a liberal (frinstace the Mass. govt and Obama) filled in the blanks, Scott would be wrong. Remember, we’re all basically on the same side here.

              • Rob in CT

                No.

                What I said was that if a liberal got to fill in the hand-wavy blanks in the old Heritage Plan, there would still only be, at best, similarity (between liberalified Hertiage and the ACA) to the extent you just ignore Medicaid expansion.

                On balance, that’s Scott/Stepped’s position.

                • stepped pyramids

                  No, I’d argue something stronger than that. The parts that Heritage doesn’t handwave are things like gutting Medicaid and Medicare, eliminating employer-provided health care, and eliminating state regulations of health care. The thing the plan is very explicit on — as in, the text spends paragraphs saying this is the intended effect — is that it creates a market where most health insurance is individual catastrophic plans, and most health care is paid for out of pocket with the help of health savings accounts.

                  That is fundamentally at odds with the ACA’s goals. It is a much more conservative/right-wing policy package.

                • Rob in CT

                  Yeah, so it not only requires that we ignore Medicaid expansion in the ACA, we must also ignore Heritage’s gutting Medicare & Medicaid.

                  Basically, the similarity is the mandate.

                • stepped pyramids

                  I am totally OK with people saying “the individual mandate used to be a major component of the conservative Heritage health care plan, and now conservatives act like it’s a tyrannical imposition”. I don’t think it’s rhetorically very useful because I don’t think Republicans in 2017 give a fuck about what some think tank dweeb in 1989 wrote up in a policy paper. Nor should they really be held to it, frankly. I don’t think the Democrats should be expected to account for what liberal think tanks thought was a good idea in 1989, either.

                • Scott Lemieux

                  Right. Even if liberals filled in the details, and even if we ignore Medicaid and Medicare, the lack of essential benefits regulations in the Heritage Plan makes it fundamentally different.

          • stepped pyramids

            Have you read the paper? It’s not particularly long and it’s written in fairly plain English. What Krugman is claiming is not based on any kind of complex economic analysis of which a layman is incapable.

        • Scott Lemieux

          And the voucherization of Medicare, which I’m pretty sure Krugman wouldn’t handwave if Paul Ryan proposed it.

      • JKTH

        I don’t know how he gets the bigger spending part. Even if you ignore the employer insurance stuff (since technically that’s taxes), the Medicaid part seems to be designed to not increase spending and the Medicare cuts would be huge.

    • Scott Lemieux

      This is just bullshit, a naked appeal to authority. Krugman is not an expert on healthcare policy, specifically. I’ve made a very detailed argument why he’s wrong. “Krugman was right about something else” is not an argument.

      • petesh

        You focused your complaint on your admiration for Krugman. “I don’t get it, you said.” You’re the one who brought up authority, only positioning yourself as the expert who knows better. Sorry, Krugman damn well is an expert on healthcare policy, which he has been deeply involved in for most of the last decade. If you don’t get it, maybe you are just wrong.

        • Hogan

          You’re the one who brought up authority, only positioning yourself as the expert who knows better.

          No, he made an argument about the ACA. Which is more than you’re doing here.

        • Aaron Morrow

          Krugman damn well is an expert on healthcare policy

          False.

          I’d go so far as to say he is an expert on fiscal policy*, but Krugman knows the difference between Medicare accounting schemes and health care policy.

          (* also macroeconomics, monetary policy, and economics as a discipline, but who would confuse health care policy with those?)

          • BaronvonRaschke

            He is an expert on macroeconomics for sure, but he is as much of an expert on health care as he is on trade. And don’t forget that the Internet will be no more important than the fax. I keep waiting for the K-man to say that stocks have reached a permanently high plateau.

        • Scott Lemieux

          All lies. I didn’t appeal to anyone’s authority, and Krugman’s academic expertise is not healthcare policy. He made a nontechnical argument based on public documents, and the argument is wrong. Your naked appeal to authority is in fact tacit admission that the argument is wrong although you’d like it to be true.

          • petesh

            Do NOT accuse me of lying. Period.

            • Scott Lemieux

              I will accuse you of lying when you lie, which you clearly did here.

              • petesh

                Bullshit. You will apparently accuse me of lying when you think I know something in contradiction to my statement. You do not know that, you are simply being offensive. As I have said, I may be wrong. But you are using insult as argument, and that is NOT persuasive.

                • Scott Lemieux

                  LOL you have literally made no arguments here and have offered nothing but personal attacks.

        • Craigo

          He’s not an expert on health care. Krugman himself wouldn’t say that he is. That’s not a remotely defensible assertion.

          • petesh

            In my view, Krugman is a more reliable source of authority on healthcare than Lemieux is. (He presents himself as “a professor of political science at the College of Saint Rose in Albany, N.Y., with a focus on the Supreme Court and constitutional law,” and he is really good on those subjects.) I may be wrong but I am NOT lying. This is, however, a perfect example of attacking a fucking ally. My first comment was intended as a gentle and slightly humorous disagreement. Now I am angry. See how that works? I’ll get over it, and I shall doubtless appreciate many more of Scott’s posts, but looking backward and yelling at people is not how you do effective politics.

            • Scott Lemieux

              Again, this is bullshit. I didn’t appeal to my authority — you just lied about that. I made a specific, detailed argument on the merits based on a non-technical public document. The argument is either right, or it is wrong. Your naked appeal to authority is a tacit admission that my argument is right, although you really wish it wasn’t.

              • petesh

                Of course you appealed to your own authority. You wrote a post explaining your argument and making your opinion clear. Accusing me of lying is beyond the bounds of civilized discourse. You know that.

                Dammit, looking forward I almost certainly agree with you. Stop looking backwards and stop accusing me of bad faith.

                • spencer_e9876

                  “Of course you appealed to your own authority.”

                  Not that Scott needs my help, but he really didn’t. Simply making an argument is not an appeal to authority, and if you think it is, then you might want to look up the definition of that specific logical fallacy.

                • Scott Lemieux

                  Of course you appealed to your own authority. You wrote a post explaining your argument and making your opinion clear.

                  I see — your argument is that you weren’t lying, you just don’t even understand what an appeal to authority is. Fair enough!

                • petesh

                  Look, if I did not know how to define the term before, which I probably did, I learned in in 1967, in my freshman year at Oxford. That is an appeal to my authority. Got it? I am still awaiting an apology for your rudeness.

                  ETA That’s where I learned not to be impressed by academics

                • Scott Lemieux

                  Well, if you know what an appeal to authority is you were lying, because I didn’t make one. Take your pick!

                • petesh

                  Nope. Anyway, you accused Obama of lying too, so I’m in good company.

                • Are you saying you didn’t lie because Scott allegedly accused Obama of lying?

                • “That is an appeal to my authority. Got it?”

                  Got it alright. You are making an appeal to authority to argue that you could not have possibly misused the term.

      • Kevin

        Also, Krugman is making a prediction in the DeLong piece based on his excellent background in Keynsian economics. On the ACA, he is quite clearly exaggerating it’s similarity to the Heritage Plan. We don’t have to wait for his prediction to be verified, we can judge the similarity for ourselves. And, as Scott demonstrates, he isn’t correct.

  • Murc

    But what conservatives really want

    I thought motives were irrelevant.

    • Rob in CT

      How about “what conservatives keep trying to do” instead?

    • Murc

      Ugh, you know what? I’m being overly shitty about this. It’s a strongly-held view on my part but that’s no reason to dump it all over an unrelated thread. That’s my fault, and I apologize.

      • s_noe

        Your point on the importance of motivation added nuance to SL’s argument, but I doubt you guys really disagree about this very much.

        (Fuck, lemme save that last sentence as a boilerplate comment on like 90% of online intraleft disagreements.)

  • King Goat

    I’m not sure about the political argument. Obama himself would mention that the ACA was modeled on the Heritage Plan, and I think that demonstrates that he thought that argument helped the ACA.

    • Scott Lemieux

      Yes, Obama thought this lie would attract Republican support. He was utterly wrong. But even if he had been right, there is less than no value to lying about this now, when it does literally nothing but help Republican claims that their attacks on the ACA are moderate and they share the same basic goals.

      • King Goat

        He would say that long after the ACA passed, though.

        • petesh

          Obama stressed that in an exit interview. His point was that he was surprised by the lack of Republican support.

        • Scott Lemieux

          Yes, he did continue to use a dumb rhetorical tactic after it was a proven failure. He’s definitely not infallible!

      • Rob in CT

        I think the glaring hypocrisy of the GOPers on the mandate shocked quite a few of us, including Obama, and this morphed into “they’re against their own ideas now!” and people got a little… fuzzy on the details.

        • postmodulator

          I feel like this is probably the best explanation. The extent of GOP hypocrisy is still a little breathtaking, just the willingness to contradict positions they took yesterday that were recorded on video and everything.

        • Scott Lemieux

          I have no objection to bringing up the mandate in the Heritage Plan in the context of the legal attack on the mandate. This goes wayyyyyyy beyond that.

      • politicalfootball

        there is less than no value to lying about this now

        Krugman invokes the concept of a responsible Republican Party to show Republicans and Democratic moderates how far beyond the pale the current Republican Party is. This creates room for Republicans to mirror Reagan: “I didn’t leave the Democratic Party; the Democratic Party left me.”

        • postmodulator

          Which nearly five of them do every year.

          • Howard_Bannister

            In my own little group of fully indoctrinated right-wing nutballs…. the one I grew up with before un-drinking the Koolaid… it’s been about one a year?

            It’s a little disheartening to think my community of only fifty people could represent one-fifth of the gains from the ranks of the wingnuts. (wink, smiley-face, gentle ribbing)

        • Scott Lemieux

          Well,it ain’t working, so I propose telling the truth instead.

    • AlexSaltzberg

      One of the big arguments against the ACA is (and was) that it lacked the sanctification of bipartisanship. By pretending that it was rooted in a Republican plan, it’s an attempt to create an appeal to the media pundits who provide the bipartisanship benediction.

      • King Goat

        Yes. Additionally I think it was supposed to turn back the argument that it was some radical socialist scheme.

        • Nick056

          Obama emphasized the similarities because his political team did not want to sell this as a large expansion of the welfare state. It was! Medicaid up to 138% of FPL, with loosened eligibility, coupled with subsidies for individually purchased insurance for up to 400% of the FPL, and CSR payments for people below 150%, actually represents a lot of money, largely paid for through taxes, a grab bag of Medicare cost control techniques, and agreements by industry players to help cover certain costs through taxes or fees or rate changes, based on the expectation of A BAILOUT (read: higher revenues).

          So he could have said, roughly, that. Or he could have hugged Heritage. He hugged Heritage. I don’t get quite as exercises about it as Scott, because I don’t know that straightforwardly admitting the redistributive elements of the plan is great politics, either, and in any case the same reliance on path dependency does exist in both plans, which is why Krugman makes this point. It IS more market-oriented than something like Kennedy’s pitch from the 70s.

  • Steve LaBonne

    This was perhaps the most disappointing column I have ever seen from Krugman. Extremely sloppy and as you say, very pernicious.

  • Rob in CT

    I read that earlier today, and noticed that Krugthulu didn’t mention Medicaid expansion. Sigh.
    I understand the idea behind this argument (basically: conservatives have gone batshit), but, yeah, it’s past time to retire it.

    • Steve LaBonne

      Like many others, I keep crying in the wilderness that Medicaid expansion is by far the more important part of ACA. Roberts didn’t help with making that argument, but it remains true even so.

      • sibusisodan

        It’s taken me a while to understand that, and its significance. Largely thanks to Scott in posts and you and others in comments.

        • Rob in CT

          Ditto.

    • Incontinentia Buttocks

      Any argument that “conservatives have gone batshit” that rests on implying that they weren’t batshit in 1994 (or 1984 or 1974 or 1964 and so forth) by definition misunderstands the batshittedness of conservatism. It isn’t an unfortunate turn that the right has taken due to Trump or W or Chaney or Gingrich or Atwater or even Reagan. It’s in the very nature of modern conservatism. And until we put away the illusion that there’s a sensible, reasonable, and honorable strain of American conservatism to be found in the recent past, we will continually make the mistake of imagining that we can separate a small basket of deplorables from a fantasy body of folks that we can learn from, have honorable disagreements with, and reach nice, bipartisan solutions in tandem with (let alone that those solutions would look like the ACA).

      • stepped pyramids

        I agree. The Heritage plan could easily form the basis for a terrible GOP Obamacare replacement bill today, and it’d be more right-wing and extreme than even the AHCA. Maybe they’d replace the mandate with their “totally not a mandate” idea to have insurers fine people instead of the IRS, but otherwise I think Paul Ryan would be happy to pass a bill based on that plan today.

        • Scott Lemieux

          The AHCA, BCRA, and especially HCFA were all substantially more moderate than the Heritage Plan. Not even close.

      • sibusisodan

        Is ‘Conservatives have relentlessly pressed the frontier of batshittedness’ a bit better?

        By today’s standards, Gingrinch et al look charmingly little league. By the standards of their time, they were very definitely standing outside the Overton window yelling stop.

      • BaronvonRaschke

        Conservatism is a brain defect. How can you reason with people who think the ACA is too liberal?

  • Joe Paulson

    Medicaid expansion alone (even after the Supreme Court activist in a bad way style altered it).

    I understand if you want to in some big picture way want to say that once you accept Heritage that you can’t reasonably see ACA as a big threat to constitutional freedom or anything, but Krugman has a curious spin on the specific details.

  • stepped pyramids

    Thanks, Scott. I was pulling my hair out over this. I tweeted at him but I don’t really have any hope that he’ll read it. You actually have a platform here and as we see there’s still a lot of people who are repeating inaccurate information about this.

    ETA: The other thing worth noting is that the Heritage paper is very broad-strokes. It’s not a fully realized plan at all, just a statement of principles and a laundry list of possible reforms. It’s the embryo for a plan, not an actual plan. Which makes me wonder why Krugman makes confident claims about its effect on federal spending on health care — there’s barely a number in the whole document.

  • sanjait

    It’s not actually false. Krugman is just emphasizing a different aspect of a sprawling issue.

    Krugman is pointing out that the three-legged stool structure of the ACA individual exchanges is the same in principle as the Heritage Plan. This is potentially useful to observe to counter the insane rhetoric from conservatives about the evil of that three-legged stool design.

    Particularly the mandate leg, which almost didn’t make it past a SCOTUS in which conservative justices bought the argument that it amounted to liberals taking away freedom.

    That hypocrisy matters, because HeritageCare and RomneyCare were indeed similar in that regard to ACA. But so too does all that Scott discusses matter, because the details matter.

    Maybe “myopic” would be a better word for Krugman here, but I’m not personally convinced he’s wrong to focus on that hypocrisy. Scott says it leads to less informed observers making bad conclusions, which is a real risk, but I don’t know how to gauge that.

    • stepped pyramids

      He makes specific factual claims (it’s “pretty close” to the ACA, it “would have required bigger, not smaller, government spending”) that are misleading at best, and he uses language that makes it sound like he’s covering the total difference between the plans (referring to the singular “piece of the ACA that Heritage didn’t want”, saying “where the plan differed was in the handling of pre-existing conditions”). It’s like saying that a minnow is “pretty close” to a a man because they both have hearts and bones.

      If someone feels the need to compare the plans (I agree with Scott that it’s rhetorically pointless or worse), they should specifically call out that they’re addressing the mandate + subsidies structure, and that the plans are otherwise quite different. Doing anything else is intellectually lazy to the point of dishonesty.

      • sanjait

        “pretty close” is not a specific and factual claim.

        And a minnow is pretty damn close to a man if you look at the tree of life and see that both are near the end of one particular branch. As a former microbiologist, I think minnows and humans are remarkably similar, from their genes to their cells to their structures.

        See how perspectives matter and are not given to be identical?

        Intellectually lazy, arguably. Misleading, maybe, if we assume audiences make bad assumptions. Dishonest, not at all.

        • stepped pyramids

          Fair enough on “pretty close” not being a specific and factual claim, but completely disagreed on everything else. Krugman is writing for a popular audience and is clearly not making an abstract claim about the plans’ evolutionary similarities. He mischaracterizes the plan, plain and simple.

          • sanjait

            Evolutionary similarities … seems to me a remarkably apt term for what he was pointing out!

            Another example of differing perspectives I guess.

            • stepped pyramids

              Overall, what’s striking about the Heritage plan is that it’s not notably more conservative than what Obama actually implemented: a bit less regulation, a substantial amount of additional spending. If Obamacare is an extreme leftist measure, as so many Republicans claim, the Heritage Foundation in the 1980s was a leftist institution.

              First, “a bit less regulation” is an inaccurate way of saying “one plan makes the market significantly more regulated, and the other plan makes the market significantly less regulated”.

              Does “the Heritage plan is not notably more conservative than the ACA, other than slashing regulations and spending” really make a lot of sense as a thesis to you? Regulations and spending are the major macroeconomic differentiators between the right and left in the US. Krugman isn’t making the abstract argument you seem to want him to be making.

              • I also think it’s really important to note the “preserve most existing insurance structures” and “eliminate almost all of them” difference.

                That the ACA strengthens Medicaid while the Heritage plan breaks it. This is continuous with the various repeal plans that go far beyond repeal and try to destroy pre expansion medicaid as well.

                • stepped pyramids

                  There’s an argument one could make the ACA is more “conservative” in a formal sense than the Heritage plan, because it preserved most parts of the existing health system and simply reformed and added various parts, while the Heritage plan strips down and reshapes virtually every government intervention in health care. But that’s not what “conservative” means in American politics.

                • sanjait

                  Plausibly a robust system of public financing for private insurance purchases obviates the need for Medicaid.

                  Like in Switzerland, which is another evolutionary predecessor to HeritageRomneyCare.

                • Plausibly, a sufficiently generous block grant program indexed to inflation and need and determined per capita would be great! Throw in some ponies and hurrah.

                  In the context of US politics, destroying medicaid means destorying poor people’s health insurance. Block grants mean cuts.

                • sanjait

                  Are we debating whether an outline of a plan with no numbers would have provided adequate funding for poor people’s health insurance? I challenge the premise.

                • I…don’t know what you’re doing. You made something up that seems pretty useful for current discussions and I made up something analogous to demonstrate the problem of such lines.

                • Scott Lemieux

                  Whatever, but that’s not what Heritage was proposing.

              • sanjait

                “Regulated” is not an easily defined linear measure. “Conservative” is not an easily defined linear measure.

                The accusation that Krugman is somehow factually “wrong” seems to stem from the assumption that those are indeed easily defined linear measures.

                The Heritage plan adds regulation because it adds a mandate. It is unconservative because it increases spending.

                Yes this is simplistic, and arguably people will interpret those claims in stupid ways. But they are not factually wrong.

                And there I go for a second time today being pedantic, which means I should really get back to work.

                • Hogan

                  The Heritage plan adds regulation because it adds a mandate.

                  Yes, it regulates consumers. The ACA also regulates insurance companies. If anything, the Heritage plan deregulates insurance companies. That’s conservative.

                • sanjait

                  That’s not entirely true.

                  The Heritage plan is a relatively short document, that doesn’t spell out all the details, but it calls for “adequate” coverage requirements. That’s de facto a call for insurance standards.

                • Scott Lemieux

                  It also very clearly says that the goal is to fund most medical expenses out of pocket and that insurance should essentially be catastrophic. For everyone! The idea that this is a minor difference is insane. You’re trying to charitably interpret lacunae, but to do that you have to completely ignore the clear structural goals of the plan.

                • William Zame

                  But the lower-level ACA plans are indeed basically catastrophic insurance (i.e. they have high deductibles).

                • See my comment quoting from the actual plan, not the summary of the plan. The actual plan is 127 pages. It clearly says that “adequate” means “catastrophic”. To be fair, they are cagey about it, but see my comment with quotes.

                • “Regulated” is not an easily defined linear measure.

                  Oh come on.

                  The Heritage plan adds regulation because it adds a mandate.

                  And require removing state mandated benefits. So it is *net* deregulation. This isn’t hard.

                  It is unconservative because it increases spending.

                  I believe it is revenue neutral. Everything comes from 1) shifting the employer tax exemption, 2) killing existing premiums etc., and 3) weakening benefits to catastrophic coverage.

                  Maybe there’s a bit more in toto, but I didn’t see any specific funding mechanisms.

                  Yes this is simplistic, and arguably people will interpret those claims in stupid ways. But they are not factually wrong.

                  Even if you manage some hypertechnical sense in which they “both” increase regulation and increase spending, this is exactly missing the point. The heritage plan is an attempt to cut spending and regulation. We know this because 1) they told us! and 2) their specific proposals all tend that way. The ACA is the reverse.

                • Scott Lemieux

                  it is unconservative because it increases spending.

                  I forget who pointed this out earlier, but there’s no actual basis for this. The Heritage Plan cuts the employer tax credit, Medicare, and Medicaid. It is enormously unlikely that any implementation of this plan would increase spending, and no chance at all that any Republican implementation of the plan would increase spending.

        • Veleda_k

          “Pretty close” is not a specific claim, but I don’t think it’s too much to demand that “pretty close” should mean “more points in common than different.” Can somebody offer me evidence that the Heritage Plan and the ACA are more alike than different?

    • Rob in CT

      I think the better line of attack on hypocrisy is to keep noting how many times conservatives have attacked the ACA for things that they actually want to make worse.

      • sanjait

        That’s the one I’d choose as well at this moment too.

      • DAS

        The trouble with this is that the GOP claims that their plans for “things they are attacking the ACA for” will make those things better not worse. And most people simply (even some people who have a good amount of economics knowledge in general) are not in a position to evaluate the GOP’s claims. So any attacks on GOP hypocrisy for attacking “the ACA for things that they actually want to make worse” will thus degenerate into “Democrats attack the GOP for hypocrisy but Republicans just say they are fixing the ACA”.

        • Rob in CT

          Well, yes. They lie shamelessly, and a lot of people buy it.
          There is no easy way to counter this.

          • sanjait

            Debate in the post truth world … is frustrating.

            • sibusisodan

              Ain’t that the truth…wait! Is It?

              • spencer_e9876

                Views differ!

    • Scott Lemieux

      No, as sp says this isn’t right. He’s not just making the claim that the structure of the exchanges is superficially similar (which is trivially true or greatly misleading depending on how it’s worded.) He’s saying the ACA is fundamentally similar to the Heritage Plan, which is not remotely defensible.

  • People keep harping on some fairly superficial resemblances between ACA and Heritage. I mean, ok, the mandate is an important feature of ACA but Heritage never promoted a system to tax the rich in order to greatly expand coverage for lower and middle class Americans through government subsidies and Medicaid expansion: the greatest expansion in publicly funded health care since the 1960’s, and probably the most redistributionist government policy (leaving aside Republicans’ upper class tax cuts) since then as well.

    • sanjait

      Yes, the mandate is an important and not superficial feature here. Otherwise the skinny bill would have been a superficial threat to the system.

      • Yes, it is an important feature but the overall resemblance is still superficial given the many, many important differences.

        • sanjait

          Seems like you’d like to have it both ways. At the risk of being overly pedantic … superficial and important are antonyms.

          • Both ways? What are the ways?

            1) A specific feature of the plan, and its importance to the plan’s structure
            2) The overall impact of the plan once all the important features are accounted for.

            So, consider 1: the two plans share an important feature. That on its own is not a superficial resemblance. However:

            Consider 2: once all the important features of the plan are considered, the impacts of the two plans are drastically different. This means that saying the two plans are fundamentally similar based on just one of the plan’s important features is a superficial comparison of the two plans.

            So, technically, in a very narrow sense, you are correct that I am “having it both ways”. And so?

            • sanjait

              And so … the three-legged stool is a pretty dang important and not at all superficial aspect of ACA.

              I’m not speaking in code here. I don’t think the three-legged stool becomes “superficial” if you take a wider view of the “overall” bill, but I acknowledged such a term is subjective.

              • This is like saying this a pertinent comparison:

                1) A car uses a motor,
                2) A water pump uses a motor
                c) Therefore a car is pretty much the same kind of thing as a water pump

                Because the common element- the motor- is an essential element of both.

            • sanjait

              Let’s get quantitative on overall impact.

              More than half the coverage expansion under ACA not including the under 26 provision was in Medicaid enrollees. With the rest, about 40%, being exchange enrollees.

              So that’s two-fifths that are there because of the three-legged stool.

              But that’s not all, because a huge portion of the Medicaid newly-enrolled are not newly eligible, but in fact just the result of some “woodwork” effect. ACA made them more aware of the available coverage, made it easier to sign up for coverage, and … implemented a mandate for coverage.

              http://www.nejm.org/doi/full/10.1056/NEJMp1609016

              It’s not possible to disentangle those drivers of woodwork effect, but we can safely guess the three legs of the stool are directly responsible for about half the expansion, and that’s if we choose not to regard expanded Medicaid as merely a channel for delivering subsidies.

              • Similar reasoning:

                1) A camera tripod has three legs
                2) A three-legged stool has three legs
                c) Therefore a three-legged stool is pretty much the same sort of thing as a camera tripod when it comes to its main function, which is supporting weight

              • “that’s two-fifths that are there because of the three-legged stool”

                That’s two-fifths that are there because of the three-legged stool AND the subsidies, which is another important element not in the Heritage Plan. Moreover, there is the minor point of what kind of plans the Heritage Plan was talking about compared to those people can access under the ACA. And then there is the other small matter of what Heritage proposed to do to Medicaid (hint: the total opposite of expanding it).

                • Scott Lemieux

                  And the insurance people can buy from the ACA’s stool is much better than the stool they could buy from the Heritage Plan. That’s not some minor quibble. Would Krugman describe the Cruz Amendment as a tweak?

          • Hob

            Your point isn’t “pedantic”, it’s just remarkably illogical. Did you really not notice that two different levels of thing were being described by those antonyms, and that a_paul’s sentence very clearly explained why one outweighs the other? “An eye is an important feature, but the overall resemblance between a human being and an octopus is still superficial given the many, many important differences.”

            • sanjait

              I get that you guys think the subjective assessments of weight of importance you have are the only right way to view the situation. I really do get that.

              • Hob

                If you think “superficial and important are antonyms” is a meaningful response on any level, even a nitpicky one, to the comments you were responding to, then there’s definitely something you don’t get.

                • sanjait

                  You’re right, I have no idea what your point is here.

              • Hob

                I mean, your previous comment (“Yes, the mandate is an important and not superficial feature here”) made sense. This one doesn’t. That’s all.

              • Scott Lemieux

                Again, the “three legged stool” comparison is superficial. It completely ignores 1)the very different insurance offered on the ACA’s exchanges and 2)the Heritage Plan’s destruction of Medicare, Medicaid and employer-provided coverage,which makes the lack of comprehsive insurance vastly more important. These radically different plans aren’t similar because Heritage recognized the banal point that markets have to incentivize healthy people to work.

                • And don’t forget the key theoretical mechanisms in play. The heritage plan says, “Costs are to be controlled by skin-in-the-game consumers and that’s it”. $20k (in today’s dollars) for the elderly are a great thing! Kill the cost raising state mandated benefits.

                  It’s everywhere. “Routine” costs are to be paid outright by patients. Not copays…full costs. The model is car insurance. You buy and large don’t pay for insurance cover for routine maintenance, but only for catastrophic (which ignores extended warranty plans, but whatever).

                  The ACA starts by saying, “high value plans for all” and controls patient costs by regulation (e.g., 80% mandated medical loss ratios), subsidies, subsidies for out of pocket costs, mandating free essential services, etc. The ACA is closer to regulated insurance systems in the EU. The Heritage plan rebels against that.

  • Kevin

    I’m a fan of Krugman, didn’t get the hate on him during the primaries (that was before I realized that anyone who spoke ill of Saint Bernard was a target), but as soon as I read this column, I thought of all the times you had debunked it. Hope he reads this!

    • Incontinentia Buttocks

      The problem wasn’t that he spoke ill of Sanders. The problem was the quality of his arguments about Sanders. Krugman is usually very good. But he’s entirely capable of getting into argumentative ruts that leave him writing columns with weak arguments. Primary campaigns lead many folks to embrace a more-or-less mindless form of support for their chosen candidate. This was true of a lot of folks on both sides of the Clinton-Sanders divide last year. Krugman was one of them.

      • Kevin

        I found no problem with his arguments against Sanders, and had similar concerns myself. I’d love to hear which of his arguments was “bad”.

      • stepped pyramids

        I thought he made pretty weak arguments against Obama in 2008, too, other than his very valid critique that Obama’s health plan wasn’t workable without a mandate.

        • Incontinentia Buttocks

          I totally agree, sp. When he started in on the Sanders stuff last year, I immediately thought of his largely weak and tendentious anti-Obama pieces from eight years earlier.

        • Kevin

          His arguments against Obama and Sanders seemed to be “this rhetoric is kind of phony and not the way to govern”. In Obama’s case…he was proved right in the end. So i don’t see why that’s a problem with his Sanders critique.

  • NeonTrotsky

    You’re not wrong really, but I think what Krugman is getting at is that Conservatives were fine with the idea of an individual mandate before it became associated with Obama. The ACA is something that internally consistent moderate Republican types of a different era should have supported, and it’s the closest there is to a truly market based attempt at expanding healthcare coverage that actually expands coverage, and pointing out this hypocrisy is a useful tool for attacking Republicans. It shows they have no commitment at all to expanding coverage, and all the high minded language about market based solutions is just a cover, they don’t actually have an ideological commitment to markets at all, just to naked appeasement of rich corporate donors and class warfare against poor people.

    • sanjait

      That, and they also nurture deranged opposition to anything the Black Guy did based on thin pretense.

      To me that is what Krugman’s observation highlights.

      • Scott Lemieux

        But this is just flatly false. The ACA consists almost entirely of things conservatives hate. It’s like saying Bush’s Social Security privatization scheme was motivated by animus against FDR.

    • Scott Lemieux

      No, this is not anything conservatives should have logically supported ever. It greatly expands public insurance for the poor, regulation on insurance industries, taxes, and spending. Conservatives hate all of these things! The idea that conservatives should logiclly support those things because some conservative plans also had a tax penalty on the uninsured is bonkers.

      And this is why these arguments are so pernicious — they imagine conservatives want to expand the welfare state they want to destroy.

    • BaronvonRaschke

      It is trying slowly to move into this century after the 2016 shellacking. Erik Loomis points out in his critique of Schumer’s better deal that it shows how far the Dems have come since 2000. Then he skewers the proposal. The notion of employer tax credits for training instead of a real jobs program is ludicrous. Like Loomis, I am far closer ideologically to Bernie than to Schumer, wall Street’s front man.

  • petesh

    Aaaand, here we go looking backwards again. I regret getting involved. But I also regret Scott’s tendency to shoot his fucking allies.

    • stepped pyramids

      “The ACA is a Republican plan” is ammunition for inter-left warfare. People are going to be linking to this as a “see, even Krugman says it” trump card in favor of that argument for ages.

    • Lost Left Coaster

      Get a grip. That is not a fair characterization of Scott’s critique.

      • petesh

        Look, this is the guy who titles (and frequently concludes) otherwise excellent posts with sarcastic sneers about both parties being the same (which he is ridiculing ad infinitum and a bit beyond). I am not the first person to complain about that. And his response to my first comment? “Bullshit.” O-Kay. He raised the stakes, I ain’t backing down. His post was uncalled for, inappropriate, backward looking and politically damaging.

        I want a version of healthcare that works. The ACA was (and is) an incremental step. What is the next step? That’s a post I’d like to engage with. For now, I’m done on this one.

        • It might be better to be done with such posts earlier.

          Scott’s post is as backward looking as Krugman’s.

        • BaronvonRaschke

          Well said both on substance about the PPACA and on style. He started an argument with me yesterday by calling me a “dumbshit” and asserted I know nothing. We disagreed but there was no call for for the ad hominem. (I probably should not have said he was a clown without the red nose and shoes, but I did.). I find in him an arrogance and condescending manner that seems a bit overwrought and hard to justify.

          • As I recall, during that debate you referred to the ACA as the “Heritage Foundation Rube Goldberg contraption”. While I would not use the insults Scott used he was right to ridicule that claim then and he is right to do so here.

            • BaronvonRaschke

              I still see the insurance exchange as too similar to the Heritage plan to make a distinction. Let’s move beyond that. It most certainly is a Rube Goldberg contraption, way more complicated than it needed to be My fundamental problems with it are that (1) it does not insure enough people, (2) does not get the insurance companies and their rent-skimming out of the process (which, to the best of my knowledge, every other OECD nation has done), and (3) it has not lowered insurance costs. At best, I am willing to view the ACA as an incremental step in a process.

              My deeper problem is that the Democratic Party leadership does not support single payer. There is a huge chasm between progressives like me and the party establishment. I had done a fair bit of minor league lobbying in the past, and I saw it on nearly a daily basis. (I sheepishly admit that it helped me and my clients back then, but I do not feel good about that.) Scott will settle for what the Dems have to offer. I can go along with that in 2018, but I want better from the party. Trump is a carnival barker, and he will implode. I do not want Trump to be replaced by Hillary 2.0 or Obama 2.0 I want a progressive Democrat to be the standard bearer, not someone from the wing that drove the party into an electoral ditch. The debate below will not go away. (I really like Sen. Amy. I would love to see her run for president.)

              http://www.truthdig.com/eartotheground/item/health_care_sows_rift_progressive_left_democratic_party_stalwarts_20170730

              • “I still see the insurance exchange as too similar to the Heritage plan to make a distinction.”

                So, you too are captivated by superficial resemblances! That does not bode well for you potentially making serious arguments on this issue.

                So, what else do we have

                “way more complicated than it needed to be”- possibly, although some countries with universal systems have fairly complex arrangements for ensuring this.

                “it does not insure enough people”- true.

                ” does not get the insurance companies and their rent-skimming out of the process ”

                Since you mention OECD countries, I inform you that most of them have not, in fact, cut private insurance companies out of the health care game.

                UK- Private health plans exist alongside the NHS

                France- Public health coverage supplemented by private insurance

                Canada- Aside from special populations, private insurance required to cover drugs, dental, eye checkups

                Australia- Public health coverage supplemented by private insurance

                Germany- A mix of public and private funds insure universal coverage
                Employees above a certain income level must have private insurance; everyone else is enrolled in a public plan.

                Sweden- mostly government funded but some private insurance.

                Netherlands- According to OECD report “Extensive reliance on market mechanisms in regulating both basic and “over the basic” insurance coverage and abundant private provision of health care.”

                Switzerland- ditto

              • William Zame

                A number of OECD countries have private health insurance at the center — but insurers are highly regulated and profits are restricted. Health insurance companies are treated like utility providers: as regulated monopolies.

        • “His post was uncalled for, inappropriate, backward looking and politically damaging.”

          Seriously, come off it. If people who are basically on the same side cannot critique each other’s arguments, and we know that those on the other side make arguments in bad faith, it follows that we needn’t listen to any critiques at all. In fact you keep implying that any critique of someone’s arguments is a personal attack, which means there can by definition be no friendly, constructive criticism at all. In that case political debate can never be anything more than a dialogue of the deaf.

          Also, the “backward looking” comment is odd. Is history “backward looking”? Why yes! Why then do we study it? In part, to understand how we got to where we are now. That would seem to be an important thing to understand if we want to move forward, no?

    • sanjait

      I’m quibbling with Scott here, and I’m personally highly sensitized to what I perceive to be a hair trigger tendency among some lefties to attack Krugman for just opening his mouth, but …

      This dispute seems mild and inconsequential to me. It’s not a dispute on policy grounds or principles, it’s a dispute about how to properly characterize something so third party audiences don’t get the wrong idea. Doesn’t seem like the kind of thing people would hold grudges about.

      • stepped pyramids

        I like Krugman. This is not about him, it’s about his argument.

      • Scott Lemieux

        I have no grudge against Krugman at all, of course. He’s just wrong about this thing.

    • This is an attack on Krugman’s argument, not a personal attack on Krugman.

      • Hob

        No shit— for crying out loud, the post both begins and ends with disclaimers about how good Krugman is on everything else! “Shoot his fucking allies”?! I wish someone would shoot me with such gentle ammunition!

        • djw

          Yeah, I mean, FFS, if I’m as wrong as Krugman is here, please tell me! I can handle it. No one is right about everything all the time. A willingness to tell someone they’re wrong when they’re wrong is part of what it means to take them seriously and treating them with respect.

  • JKTH

    The Medicaid part is very vague and hand-wavey but again could be interpreted in a way where the concept is similar to the ACA if you’re being generous. Linking eligibility to poverty is what the ACA did, though the way Heritage discusses it, it makes it sound as if it would be set at a point where it wouldn’t actually increase spending (which would be a big difference from ACA). And the part about changing how Medicaid operates is out of date since managed care’s been an increasingly important part of Medicaid, especially in the expansion. I didn’t see catastrophic insurance mentioned.

    That said, the Medicare changes alone are huge enough that the plan clearly stops being similar to the ACA in both concept and details.

  • Rob in CT

    Another point that could be made more: “The Heritage Plan” was vaporware. Chait’s “The Heritage Uncertainty Principle.”

    http://nymag.com/daily/intelligencer/2013/12/heritage-uncertainty-principle.html

    • Scott Lemieux

      Especially important when people try to throw the 1993 Chafee plan (much worse than ACA, better than Heritage, pure vaporware) into the mix.

    • Drew

      I still think that’s one of the funniest things Chait’s ever written.

  • Ome Ga

    You make a really good case here for why PK is wrong. I would like to see if he makes a response to this.

    That aside can I ask what difference it really makes? You have to work with a profoundly ignorant voter base, some percentage of which thought that Obamacare and ACA were two different things. Many others just thought that Obamacare was a web site that didn’t work. And another big chuck was just simply hating it because it was Obama.

    The ACA was persistently unpopular from the day it was signed until the Republicans actually had the power to undo it. Only then did it get polls more than 50% in its favor. The reason? All of the sudden shit got real and people knew people or they themselves would have been deeply shafted, perhaps fatally, by repeal. All of the sudden the media started talking about what the ACA actually does rather than solely the disinformation that Trump and Republicans routinely put out.

    I find it hard to believe that the nuance of where the great idea (or pieces of) of Heritage/Romneycare/Obamacare actually came from would actually matter to one voter in a hundred.

    • stepped pyramids

      Just yesterday at this blog we had a commenter attacking the ACA on the basis that it was “the Heritage plan”. I run into people making that argument online on at least a weekly basis, and it seems to be a common rhetorical element of arguments for rejecting the Democratic party as a vehicle for left-liberal politics. This is a bad thing.

      • Ome Ga

        If that were the only thing you had to work against in defending the ACA then you would be in a pretty good position.

        There is no shortage of ways to attack or criticize the ACA which most people here would be able to enumerate so I will skip it. However you sort them out the genesis of ideas behind ACA has to be near the bottom of the list.

        I am no fan of winning based on falsehoods, but I would bet that the false notion that the ACEA is a conservative plan will help more than hurt with the low-information voter base that chants keep government out of my Medicare.

        • stepped pyramids

          That voter base is never going to be convinced that the ACA is a conservative plan. They know who signed it.

          “Democrats are Republicans in sheep’s clothing” has been the fundamental argument of the heighten-the-contradictions left for longer than I’ve been alive. Saying that the ACA, the biggest Democratic policy achievement in nearly a half century, is just a rebadged and polished GOP plan is an incredibly powerful argument for that premise. And that argument does affect low-engagement liberal voters, the kind of people who might be inclined to sit out midterms. I can tell you that I have personally met, in real life, more than 20 liberals who believed (and were disappointed by) the Heritage thing before I explained it to them. And once they got over that, it was easier to explain the good things about the ACA and help them understand how we can get from it to something better.

          • sibusisodan

            Politics – especially now – is tribal. ‘This good idea comes from the other tribe’ is a bad move in this environment.

            • Daniel Elstner

              Especially if it is factually wrong.

              • Scott Lemieux

                Exactly. If you’re going to say something false, the burden of proof is on you to show that it’s been beneficial. In fact, if anything it’s been a political net negative.

            • djw

              Right. It might have been an effective rhetorical strategy in some political environments, but not this one.

          • Scott Lemieux

            Even in theory, this idea that you can pull some kind of Jedi mind-trick to make Republicans think they have always yearned to expand Medicaid makes no sense at all.

      • BaronvonRaschke

        I resemble that remark. Like Petesh above, I consider the ACA an incrementalal step toward universal coverage.

    • DAS

      I know this is an unpopular position here, but the Democrats (and Obama in particular) needed to do a better job of informing people about what the ACA actually does. The GOP was putting out plenty of disinformation, so where were the Democrats and why weren’t they putting out information?

      • NonyNony

        All over the airwaves, selling the plan. I remember when they were doing it.

        The problem is that the media was and remains biased against progressives in general and Democrats in particular. Because you have one full-on propaganda station that pretty much all of the conservatives watch (Fox News) and you have a number of smaller non-propaganda stations that feel that they can best sell eyeballs to advertisers by presenting “both sides” to every issue. Also Democrats were in power and that’s when the corporate overlords of the media generally dig their heels in to try to make sure that whatever Dems can get done impacts their bottom line as minimally as possible.

        What this means is that Democrats – no matter what they do – get drowned out because of the massive imbalance in coverage. And that’s before we get started on how media consolidation has reduced most of the newspapers in at least the Midwest and South to editorially right-leaning papers owned by a handful of companies (many of whom also have a lock on the local television news offices as well as whatever dregs of radio newsrooms are left around these days).

        They were out there presenting their case – I remember seeing it constantly on TV “balanced” out by some Republican shill who was allowed to lie through the whole thing, even when called out on it. To a degree that’s just how the media in this country works these days, but in 2008 it was still somewhat shocking to realize just what the media had become during the Reagan-Bush-Clinton-Bush years and I still am not sure that people have sufficiently understanding of how to fight against it.

      • FlipYrWhig

        IMHO it’s an odd dynamic. The things that people like about the ACA, like guaranteeing coverage for preexisting conditions and allowing people to stay on their parents’ insurance for longer, come across as _so obviously good_ that I think a lot of people don’t give Democrats any credit for doing them. They’re just common sense! Who wouldn’t support that?

        If I’m right, the issue isn’t that Democrats didn’t do a better job of informing people about what the law actually does–but rather that Democrats haven’t done a better job of informing people about how toxic and obnoxious the Republicans’ opposition has been. But like NonyNony was saying, Democrats aren’t given a chance to break through the force field of Fox News and hate radio to be able to say those things to the people who need to hear them.

        • postmodulator

          The things that people like about the ACA, like guaranteeing coverage for preexisting conditions and allowing people to stay on their parents’ insurance for longer, come across as _so obviously good_ that I think a lot of people don’t give Democrats any credit for doing them.

          It’s a problem when the assumption from a low-information voter is “No one would take something like that away” and they’re totally resistant to the message “No one except the people you crawl over broken glass to vote for.” Again I must bring up that Luntz thing where he read the GOP platform verbatim to a GOP focus group and they just didn’t believe it.

        • sibusisodan

          I have no idea how you inform people who _refuse to believe_ that Republicans would do X, that Republicans are doing X.

          It’s some catch, that catch 22.

          • postmodulator

            Maybe it’s something to do with the aversion to partisanship that Democrats seem to have.

            I don’t feel like beating around the bush: the Democratic party base skews smarter than than the GOP base does. We all know it. This isn’t surprising given that the GOP is openly and profoundly anti-intellectual.*

            I think this leads to an aversion to groupthink — one of the most powerful motivational tools the GOP has is that their base hates us. Thinks we’re the worst, that we’re actual enemies of the US. You know how we all thought Trump would falter because he built no GOTV? The NRA ended up being his GOTV in most of the midwestern states he won. Because anyone but Hillary! She’s a Communist mass-murdering gun-taking lesbian witch argle bargle skreeeee.

            Democrats don’t want to do that. We think it’s gross. (It is kinda gross, honestly.) So the discussion is something like: “Only a monster wouldn’t protect, say, preexisting condition coverage.” And because it’s kinda gross, Democratic leaders and pundits aren’t willing to say “Yes! They’re monsters! That’s the point!” It’s all “our colleagues on the other side of the aisle…” Whereas pretty prominent GOP figures were fine saying Obama was a Kenyan Muslim Commienazi.

            *This derives from a discussion I had yesterday with a libertarian who was bemoaning the fact that the most public libertarians are, to his mind, just Republicans who don’t want to be called Republicans — Republicans who smoke pot, in the ancient formulation. He was rhetorically asking why, and I said it was probably brand damage — even if you’re naturally inclined towards conservative ideology, it’s embarrassing to be associated with them if you’re the kind of guy who has a library card.

            • sibusisodan

              I’d agree with this if it weren’t for the decade or more of evidence that anyone who describes Republicans accurately in public is merely being ‘shrill’ and is then shunned.

    • It’s definitely an intra-activist/policy wonk/high engagement folks discussion, but an important one.

      From the wider political messaging perspective, I think giving credit to Republicans for having health care plans, period, much less one that was made into law, is, on the margins, bad messaging.

  • jpgray

    But… there are both key similarities and crucial differences? You can say the two share very similar foundational principles (it would be almost impossible for them not to), or you can say they are massively unlike each other when it comes to very important particulars. Both are surely true?

    When it comes to Democratic commentary on it, whether you focus on one or the other seems to depend on who you want to shame. If you want to shame GOP-Dem equating leftists, emphasize the many important differences with Heritage. If you want to shame Obama-Marx equating conservatives, emphasize the fundamental similarities with Heritage.

    You could do something similar with other comparisons of two complex things.

    I mean, you could say Ice Ice Baby’s claimed similarity to Under Pressure is demonstrably false and extremely damaging aesthetically if you focus on the many, many crucial differences that make one much, much worse than the other, but you can’t deny a certain base (ahem) similarity if you’re being reasonable.

    Heritage shares one or two important structural bits with the ACA, and apart from that is full of awfulness. How is that not enough to point out their similarity?

    • stepped pyramids

      Heritage shares one or two important structural bits with the ACA, and apart from that is full of awfulness.

      That would be great. Instead, Krugman says they’re “pretty close” and that the Heritage plan was “not notably more conservative”.

      • Scott Lemieux

        Right. People seem to want Krugman to be making a different argument than he’s actually making.

        • And the Heritage plan to be different than it is.

          Reading the documents around the Heritage plan is astonishing. The level of dissembling is very high. You have to dig a bit to see the horror.

    • sanjait

      Good summary.

      I’ll add: Krugman is clearly more interested in shaming conservatives. That’s been his focus for years now.

      • postmodulator

        Krugman is clearly more interested in shaming conservatives.

        That’s pretty much a dry hole, there, Professor.

        • sanjait

          Maybe worth rephrasing: Krugman points out to the NYT reading audience how shameful are Republicans.

      • Scott Lemieux

        He should shame conservatives by pointing out that they have always opposed expanded public insurance and universal comprehensive insurance.

    • JKTH

      He can point out that the Heritage plan is about the most conservative FRAMEWORK you can have to get to universal coverage without sanitizing the details. Krugman’s point is generally “Republicans can’t get to universal coverage without mandates unless they want to expand public programs,” which is fine but he’s overly equating Heritage and the ACA by hand-waving the details of the Heritage plan.

    • You can say the two share very similar foundational principles (it would be almost impossible for them not to), or you can say they are massively unlike each other when it comes to very important particulars. Both are surely true?

      The first is not true. The foundational (coverage) principle of the ACA is universal, high quality, affordable coverage. (The ACA is also concerned with medical inflation and generally the high costs of US health care.) The foundational principle of the Heritage plan is affordable coverage with minimal government expense and no regard for quality.

      And the basic attitude is high regulation vs. very low regulation.

      Plus the ACA’s basic mechanism is improve, preserve, and expand existing coverage, where as the Heritage plan is nuke and replace.

      So the foundational principles are essentially opposite. They both use a mandate to combat adverse selection while some current repeal and replace plans use enrolment windows and continuous coverage requirements. But otherwise, the Heritage plan is much much close to the repeal and replace plans than the ACA.

      • From “A National Health System for America”:

        page 48: The diagnosis is that people accept Arrow, to wit, that HealthCare isn’t a normal market. Cost control is entirely a matter of unleashing prices and cost-conscious shoppers.

        Then we have
        (pg 51) Element #1: everyone must be enrolled (the mandate)
        (pg 52) Element #2: households are the primary unit responsible (i.e., not govt or employers)
        (pg 52) Element #3: Govt role is a) monitoring the market, b) subsidizing the needy, and c) encouraging competition
        (In particular, a social insurance system is a no-no.)

        Chapter 3:

        Funding: Replace the employer tax break with an individual tax break (refundable)
        Encourage people to pay for “routine” care and be required to get coverage for major, “catastrophic” family medical bills. Literally, “These tax credits should be designed to favor out-of-pocket health care purchases over the purchase of health insurance.”

        “Under this reform, Americans would receive roughly the same level of tax relief for their medical expenses as they do now” <– but employers won't have to pay the same share of premiums.

        Page77 "Of course, eliminating the taxes and premiums now paid by the elderly would leave Medicare with less money to pay benefits. This revenue loss could be offset by readjusting Medicare coinsurance and deductibles to give better protection from the cost of major illnesses, while requiring the elderly to pay more out of pocket for routine medical services."

        Page 85 Reform #4 Introduce Medicare vouchers.

        "Retirees would be allowed to choose coverage with very high deductibles, perhaps up to $10,000 [$20k in 2017 dollers) per year"

        Page 117 "Repeal state-mandated benefit laws"

        The whole underlying philosophy is shift costs to patients and the magic of the market will restrain costs, plus catastrophic care.

        • stepped pyramids

          Thanks for digging in. It’s really not that complicated a plan, as long as you’re reading critically enough to distinguish stated intent (to shift the market over to individual fee-for-service) from claimed effects (prices will go down, health care will be affordable), as well as paying attention to which policies are described in concrete terms (deregulation, tax changes, benefit reductions) and which are described in vague “we’ll work with the states to cover the shortfall” ways (the replacement eldercare program, for one thing).

          If you give it the most positive reading possible, taking all the claims at face value, it is still a much more right-wing plan than the ACA, and would be a hard shift to the right from even pre-ACA health policy.

          If you take it seriously and keep in mind the policy preferences of conservatives, you notice that the plan treats very high deductible plans as a desired end goal and does virtually nothing (other than HSAs and vague handwaving about voluntary risk pools) to address whether individuals can actually afford treatment in the private market out of pocket. Most people can’t afford $10k (certainly not $20k) out of pocket, and the Heritage plans would exempt either nothing or next to it from the deductible.

          The plan doesn’t even begin to touch on affordability of prescription medication, which is something catastrophic insurance simply isn’t equipped to handle. There’s just a huge gap that through rose-colored glasses is labeled “Market Forces Drive Down Prices, Make Health Care Affordable :)” and otherwise is labeled “Market Forces Kill Off Excess Peasants, Make Health Care Cheap For The Rest Of Us :)”

          • High deductibles are totally a proximate goal. The core assumption throughout the document is that all problems with the us healthcare system is that normal market mechanisms aren’t being used. The solution is to expose individual patients to the true cost of healthcare and let them bargain down or do without.

  • DAS

    I don’t quite see the way Krugman made his point (at least in his Op-Ed column) as something that “plays into the hands of hucksters like Avik Roy, who assert that of course conservatives want to cover everyone, but they just want to use markets.” I think the argument is more along the lines of “the GOP is so far down the right wing rabbit hole that they want to completely repeal a plan remarkably similar to one they supported”. The upshot is that one should not believe a huckster like Avik Roy because if he were really arguing in good faith, he’d be proposing only minor tweaks to the ACA rather than a separate GOP health care “plan”.

    • stepped pyramids

      Why would Roy propose only minor tweaks if he was arguing in good faith? The ACA is fundamentally repellent to his free-market beliefs. It expands Medicaid and he thinks Medicaid is worthless.

      • DAS

        If the ACA is “repellent to his free-market beliefs”, then there is something completely wrong about his beliefs and again he should not be listened to. The ACA sets up highly controlled marketplaces, with guaranteed customers (and a few requirements). If, in the controlled marketplace (with guaranteed customers for the product you are selling) you cannot make a profit providing health care coverage that is required to cover X or to meet standard Y, how are you going to make a profit providing health care coverage that covers X or meets standard Y on the open market?

        An argument that the ACA is failing because companies can’t compete under the requirements put forth under the ACA is inherently an argument that markets in general cannot affordably provide health care meeting those requirements. So unless you think that a bunch of common sense requirements (that any reasonable person would expect their health care to cover) are not things health care can actually cover, saying the ACA doesn’t work is an admission that markets don’t work.

        • stepped pyramids

          I think Roy agrees with the general premise of the Heritage plan, which is that insurance should not cover anything but unexpected large expenses, and that otherwise health care should be purchased directly from providers with cash in a minimally regulated open market by individuals.

    • Scott Lemieux

      But according to Krugman’s logic, Roy is right to say that his plan is a moderate alternative to the ACA! This just doesn’t make any sense at all.

  • sk7326

    One of the big mistakes Krugman make is a popular one I see David Atkins and other heighten the contradictions sorts make … separating the exchanges and the Medicaid expansion as if they were not the same bill. Maybe (maybe) you can talk about Heritage and the ACA vis a vis exchanges – and even then there are the issues Scott cites. But too often guys on TV ONLY talk about the exchanges when it is a relatively minor (but important!) part of the legislation.

    • stepped pyramids

      Yes, I think the root of Krugman’s error here is an implicit assumption that one can just pluck out particular “core” elements of the ACA (the ones that are of the most interest to him from a wonkish, macroeconomic perspective) and compare them to the analogous elements of Heritage 1989. That’s the different perspective @sanjait:disqus has been talking about.

      But I just don’t think that’s acceptable for someone writing for a popular audience, and I don’t think that narrow wonkish perspective survives the process of being translated into a political talking point.

      • Scott Lemieux

        I would suspect his focus on the mandate stems in part from his (correctly!) pointing out that Obama was engaged in dishonest pandering during the 2008 primaries.

    • sibusisodan

      Is it to do with the relative noise the exchange customers can make versus those benefitting from the Medicaid expansion?

    • sanjait

      Fair critique. My impression is that many others do that as well, so much that “Obamacare” has in many contexts become synonymous with “ACA Exchanges”.

      • sk7326

        I think Krugman is making a well meaning gesture here – but a mistaken one. And yes, Obamacare = The Exchanges effectively. As you’d expect, Medicaid gets swept under the rug because it goes to a relatively overlooked section of the population.

  • priceyeah

    Yeah. The tack might have been useful when Bill Clinton was in office. But to parade it around today after the worst obstructionism from the GOP is rather like a parallel phenomenon, Obama’s insistence on trying to reach across the aisle as late as 2013 or whatever. The electorate rewarded this patient adult behavior by making the Birther guy president.

  • Hogan

    OT The Mooch is out.

    • postmodulator

      Was he going for a freaking record?

      • s_noe

        Wanted to spend more time with his family, probably.

        • postmodulator

          Too bad his family gets some say in that.

  • Harkov311

    The Republicans could have implemented the Heritage Foundation plan at any time during the Bush Jr. administration. But they chose not to. This tells you all you need to know about how seriously anyone on the right was actually treating that plan.

    • “The Republicans could have implemented the Heritage Foundation plan at any time during the Bush Jr. administration”

      Maybe they realized that getting rid of Medicare and Medicaid and replacing them with mandatory catastrophic coverage private plans for everyone wasn’t going to be a vote winner.

  • Mojrim ibn Harb

    It’s a valuable rhetorical point, Scott, contrasting the GOP of yesteryear to what we have today. Despite their differences, the two plans have a couple fundamentals in common, and there was a time when the GOP was actually serious about something.

    • “a valuable rhetorical point […] contrasting the GOP of yesteryear to what we have today”

      Such contrasts are better made based on true things than on false things.

      “there was a time when the GOP was actually serious about something.”

      The only thing the GOP were ever serious about when it came to health care reform was opposing it. There’s a reason the Republicans in Congress never proposed any comprehensive reform in the 1990’s, or during the Dubya years. It’s because they saw no need to put much effort into expanding health care coverage.

      “Despite their differences, the two plans have a couple fundamentals in common”

      Overall, not fundamental enough. The idea that the Republicans supported anything like the ACA in the 1990’s is based on wishful thinking, not on history.

    • See my quotes from the plan in another comment. The plan really is “in order to control medical costs, convert health care into a traditional market plus catastrophic care; like auto insurance! Only you can die!”

    • It’s a valuable rhetorical point, Scott, contrasting the GOP of yesteryear to what we have today.

      “Back in the day, the GOP wanted to make you pay for your health care out of pocket AND be forced to buy catastrophic insurance. Today, they just want you to pay out of pocket!”

    • Scott Lemieux

      The GOP of yesteryear was serious…about destroying Medicare, Medicaid and quality employer-provided insurance. They put it in a plan and everything! Pretending that they actually wanted something like the ACA is 1)false and 2)not in any way rhetorically helpful.

      • Mojrim ibn Harb

        It is very helpful in arguments with republicans – “Hey man, this is 60% heritage foundation and 80% romneycare.” Forcing them to argue against something that has so much in common with their own previous plan is rhetorical gold.

  • tsam100

    I sure wish you didn’t have to keep saying this every couple of months to remind people of it.

  • cpinva

    “I am, needless to say, a huge admirer of Paul Krugman. But I genuinely can’t understand why he keeps making this false and deeply pernicious argument:”

    i have a similar problem with Dr. Krugman, who I am also a great admirer of normally. my issue with him is far more simple than yours, which makes me wonder why he continues to get it wrong. i even sent him an email pointing out his error, in simple accounting terms, since he’s an economist.

    my/our problem is this: Dr. Krugman keeps insisting, publicly and loudly, that Social Security doesn’t contribute to the deficit, that it is entirely self-sustaining. that is true, as far as it goes. i’ll explain for the uninitiated. first, and income statement and budget are two entirely different things. as a result, they measure two entirely different things, even though there are some elements common to both. i think Dr. Krugman, being an economist, doesn’t really fully understand the difference, and therein lies the problem.

    in 1984, Congress & Pres. Reagan passed two laws, pertinent to Social Security. One appeared in the Internal Revenue Code, as part of TEFRA, falling under the Fiscal Responsibility part of the public law. it raised Social Security (FICA) tax rates/wage ceiling amounts, for good reason. actuarial analysis showed that, as the large waves of baby boomer retirements hit, the then current rates.wage ceilings wouldn’t be sufficient to meet those obligations. the second law established the Social Security Trust Fund. it was dedicated to hold all FICA revenues collected, in excess of liabililities for the current year. again, based on those actuarial analysis. those excess funds were then “borrowed” by the Treasury, the cash exchanged for special, non-saleable bonds. these bonds to be cashed in, in years when SS payment liabilities exceeded FICA receipts.

    Here’s Dr. Krugman’s confusion: FICA is neither a revenue nor expense of the Federal Gov’t. it is an excise tax, collected by the gov’t at the source, for a dedicated purpose.for Budget purposes, it is both a receipt and expenditure. in those years where SS payments exceed FICA receipts, it must cash in some of those special Trust Fund Bonds. if, overall that year, Gov’t receipts are exceeded by expenditures, then cashing in those bonds does, indeed, create or increase the deficit, because it’s an expenditure. it just really isn’t that complicated, and Dr. Krugman is obviously a very smart guy, but this is one concept, my emails to him notwithstanding, he can’t seem to grasp.

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