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The ACA Consists of Things National Republicans Have Always Hated

[ 177 ] August 2, 2017 |


[Photo source]

There was a very good Frontline documentary about the passage of the ACA I show in American Government surveys sometimes. One drawback is that it features Howard Dean making ridiculous claims about how the statute didn’t accomplish anything. Via Chait, these comments were representative of his views at the time:

“This is a bigger bailout for the insurance industry than AIG,” former Democratic National Committee chairman and medical doctor Howard Dean told “Good Morning America’s” George Stephanopoulos today. “A very small number of people are going to get any insurance at all, until 2014, if the bill works.

“This is an insurance company’s dream, this bill,” Dean continued. “This is the Washington scramble, and I think it’s ill-advised.”

Dean sent shockwaves when he said Tuesday in an interview with Vermont Public Radio that the removal of the Medicare buy-in means Democrats should just kill the health care bill and start over.

“This is essentially the collapse of health care reform in the United States Senate,” Dean said. “Honestly, the best thing to do right now is kill the Senate bill, go back to the House, start the reconciliation process, where you only need 51 votes and it would be a much simpler bill.”

[…]

He said he also doesn’t see cost-control measures but, rather “a whole bunch of bureaucracies and a lot of promises.”

There are some good elements in the current health care bill, Dean said, but “at this point, the bill does more harm than good.”

I was very pleased by the solidarity with which the left, loosely defined, defended the ACA from Ryan and McConnell. From DSA to Joe Manchin, almost everybody recognized the urgent necessity of killing the repeal bills, and countless people observed that repeal would inflict large amounts of preventable death, suffering, and financial ruin. But what’s amazing at the time is that a non-trivial number of the people making Dean’s 2017 argument that repealing the ACA would be a “disaster” spent years arguing for Dean’s 2010 view that the ACA was a BAILOUT of insurance interests that accomplished little or nothing or maybe even worse than nothing. This was the view, for example, of Adolph Reed’s widely praised Harper’s cover story, and is the implicit claim of arguments that Obama governed in Reagan’s paradigm rather than FDR’s. As Chait says, “It is logically impossible for the repeal of an insignificant reform to be catastrophic. If it is a big deal to uninsure 24 million Americans and cut taxes on the rich, then it must be a big deal to insure 24 million and raise taxes on the rich.” I’m glad that the threat of repeal concentrated people’s minds, but it’s important not to keep making the analytical mistakes that led to the initial mischaracterization of the ACA.

The transparently false claim that the ACA was not an incredibly hard-fought reform that is one of the most important achievements of the New Deal tradition of Democratic governance but a minor or perhaps even counterproductive reform was based on using the wrong baseline, comparing the ACA not to the status quo ante but to European systems. The passage of an ACA-like model by veto-proof supermajorities of Massachusetts Democrats but signed by a Republican governor encouraged the belief that something like the ACA was just the consensus position of both parties, and the only question was whether Obama, Pelosi, and Reid could do better. This idea is transparently speciois, completely misunderstanding the basic ideological divisions between the two parties that started with the New Deal and have only gotten sharper.

We can see this in a couple of our recent discussions. In yesterday’s McConnell thread, for example, multiple people said that actually McConnell is incompetent because if he knew what he was doing rather than pursuing a long-odds battle to inflict major damage to the ACA, he should have just passed a bipartisan bill to stabilize the exchanges or something and called it a day. The obvious problem with this argument is that McConnell and the vast majority of the Republican conference in both houses don’t want that. They wanted to inflict real damage on the ACA and make it fail because it represents everything they hate. I mean, did you watch the vote and McConnell’s subsequent speech? If McConnell was presiding over a kabuki he strongly wanted to fail, they should cancel the Best Actor Oscar and just give it to McConnell in perpetuity. And you don’t make even marginal senators up for re-election in 2018 vote for an empty gesture you want to fail. Saying McConnell should have just worked with Democrats to pass a bipartisan bill to help the exchanges work is like saying that Reid and Pelosi were incompetent because instead of trying to pass cap-and-trade they should have just passed a bipartisan bill subsidizing the Keystone pipeline and increasing defense spending.

And the even better example is the remarkably persistent falsehood, still put forward by very smart people who would never make similar arguments about the parties in any other context, that the ACA was really a “Republican Plan.” This is the false premise of Jim Newell’s otherwise good piece — that the Republican Party secretly likes the ACA. “The ACA was like the Heritage Plan” argument is based on a similar false premise — maybe this Republican Party doesn’t like the ACA, but it logically should like the ACA, because after all old-timey reasonable Republicans we like to imagine existed liked it. Lots of people still defend Obama for being suprised by how much Republicans hated his signature initiative. But this is all ridiculous.

The ACA essentially consisted of:

  • A historic expansion of the public insurance program for the poor
  • Increased taxes on the wealthy
  • Substantially increased regulation of the insurance industry
  • Subsidies to allow the non-affluent to purchase comprehensive insurance

The core elements of the ACA that Republicans should logically like are “none of them.” The Republican Party has for time out of mind been organized in opposition exactly to this kind of reform. Its coalition has become more homogeneous and its opposition to spending for the poor and tax increases on the rich more intense, but it’s a difference of degree. Republicans inflicted a lot of damage on themselves desperately trying to repeal the ACA because they hate everything the ACA stands for and always have. It’s really not complicated. It’s hard for them to repeal the ACA because their ideas have no mass constituency and it’s hard even for popular major legislation to make it through James Madison’s sausage factory. But Republican public officials despise the ACA for perfectly logical reasons.

And what kills me is that the Heritage Plan, which is so often cited as evidence that Republicans should logically loves them some Obamacare, is explicit evidence of this! It’s a plan to destroy Medicaid, Medicare, and comprehensive employer-provided insurance and replace them with a system in which insurance covers almost nothing, and most healthcare expenses are provided out of pocket, with a bunch of hand-waving where the answers to the question of how people aren’t rich should pay for healthcare should be. It would be a considerably more radical repeal plan than AHCA and BCRA were. Republican healthcare policy preferences aren’t a secret, and are perfectly consistent with their general worldview. The mystery is why so many smart people adamantly refuse to listen to them.

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  • Yestobesure

    Would you be OK if instead of calling the ACA’s exchange/mandate/subsidy/regulation component “Republican” (which it’s definitely not) or “conservative” (you argue well that the Heritage plan is well to the right of this) we called it “neoliberal”?
    Aside from the fact that the term is just another synonym for “evil” in some parts, doesnt that word describe the mindset of technocrats like Gruber?

    • Rob in CT

      I think that’s probably reasonable, so long as one actually notices the decidedly not neoliberal Medicaid expansion.

      IIRC, the ~22 million extra insured under the ACA are split roughly evenly between people on the exchanges and people getting Medicaid due to expansion. I assume that but for SCOTUS’ re-write of the law & GOP-run states then rejecting expansion, the number of additional insured would skew toward Medicaid expansion.

      • Thom

        “I assume that but for SCOTUS’ re-write of the law & GOP-run states then rejecting expansion, the number of additional insured would skew toward Medicaid expansion.”

        That seems very likely, especially since the very populous (and with many poor people) Texas is one of the non-expansion states as things stand.

        • Rob in CT

          The ACA as originally written: ~2/3 liberal, ~1/3 neoliberal. There, sorted.

          • I think it’s a big stretch to call the exchanges neoliberal. Is the Swiss system neoliberal?

            A lot of the ACA is constraint by politics and path dependencies. The fact that health insurance is a big industry with lots of employees make for a challenging stakeholder to cope with.

            • Rob in CT

              My comment wasn’t exactly serious, though yeah maybe I’m over-conceding on that point.

              • And I’m on a tear against it :)

                • Rob in CT

                  Tear on!

            • Cervantes

              The Swiss spell out what the basic insurance product has to be. Insurance companies are paid to manage the plans, but they all have to offer the same product and they are not allowed to make a profit on it. (They can sell supplemental plans at a profit.) It is compulsory for all citizens to have the basic insurance, but if it costs more than 8% of their income, the government kicks in the difference. It’s structurally somewhat similar to the ACA, but the much tighter regulation and universality make it qualitatively quite different.

              • Yes, I agree that the Swiss model is quite a bit better and tighter…but our biggest structural disanalogy is the employer insurance market. The ACA was a giant shove toward the Swiss system. So while it falls short, it’s hard to say that it’s a neoliberal *move*.

                • Cervantes

                  If we could get all the way to the Swiss system, it would be a different story. But then you do have to ask, why have the insurance companies at all? (They could still sell supplemental policies, but why not have the basic insurance be Medicare, only better?)

                • Or medicaid, only better?

                  For me, it’s all politics and transition costs. The Swiss system is fine. The French system is fine. The German system is fine. The NHS is fine (I really love it). For me, as long as the key properties of a modern health care system (universality, quality, sustainability) are at appropriate levels, I’m indifferent to the rest. (Not personally indifferent…I love love love care being free at point of care. It’s really wonderful and I’m highly skeptical of the utility of co-pays for most care.) So, politically, in the US, I think the Swiss system is more achievable and probably more sustainable. But the landscape has shifted a bit.

                  One thing I was surprised about is how useful not deficit funding the ACA turned out to be. This is part of what made it challenging in reconciliation.

      • Yestobesure

        Very much acknowledged.
        But when the bill is criticized from the left, it’s not for expanding Medicaid but for not expanding Medicaid/Medicare enough.
        And the insincere flak the bill catches from Republicans is around issues like “mandates suck! The exchanges are failing! Your existing plan was regulated out of existence!”

        • Rob in CT

          And a lot of that flak just completely ignores the expansion.

          If it’s someone saying “the ACA was a step in the right direction but we need more” or even “the ACA is good, but single payer/Medicare for All is better” fine.

          I get annoyed when it’s more like “the neoliberal bailout of the health insurance industry that is the ACA is garbage!”

          • Scott Lemieux

            Exactly. The Dean argument treated the ACA as if it was one sentence, “please buy private insurance xthxbi”

            • Rob in CT

              Please, neoliberal hack Lemieux. It's "Thou Shalt Buy Shitty Private Health Insurance xthxbi." Pfft.

        • dmsilev

          “But when the bill is criticized from the left, it’s not for expanding Medicaid but for not expanding Medicaid/Medicare enough.”

          Of course, people making that argument often conveniently forget that the bill as passed into law expanded Medicaid everywhere and it was only John Roberts’ …innovative reasoning combining with hissy fits on the part of Republican state legislatures and governors that limited the expansion. It’s hard to blame Obama/Pelosi/Reid for that, but somehow people have managed to do so.

          • Rob in CT

            Especially Pelosi, given that the House version had a Public Option, right?

            • stepped pyramids

              I can’t even count the number of times I’ve seen people saying things like “Pelosi took the public option off the table! It wasn’t even considered!” There’s an extraordinary amount of ignorant commentary about what actually happened during the passage of the ACA, and a lot of conflation of what happened in the Senate and what happened in the House.

              Now, not everyone needs to be an expert on this. But they should at least do some research before making bold declarations about What Democrats Refuse To Consider.

              • Or that Obama DIDN’T EVEN TRY to bully pulpit the PO, or well he gave it up RIGHT AWAY, etc. Pointing all the major speeches he gave pro PO right up to it being killed doesn’t help.

              • mongolia

                but then they can’t just blame “politicians playing politics” for the problems in government, and would have to conclude that the problem is that dems try for good things and republicans bad, and then they’d have to identify as dems, and then they can’t call themselves independent thinkers (TM)

          • Yestobesure

            I meant in not covering people of all ages and incomes.

          • Hogan

            Yeah, but that’s the Democrats’ fault for writing a bill Roberts could interpret that way.

            • the actual Bajmahal

              Almost as if repub Roberts had no agency of his own.

        • tsam100

          Well, much of the criticism from the ostensible left is as wildly misinformed or willfully disingenuous as right wing criticism. Neoliberal could be applicable in the sense that it mandates buying insurance and then makes insurance affordable via subsidies and regulation (rather than just tanking the industry and going with some form of single payer), but the Medicaid expansion is straight up socialism, even if it gives states some latitude on how to spend it, which I feel is a pretty bad idea because Texas and the like.

          I’m still not sure that classifying it as anything other than an expansion of access to health care has any value other than providing attack points.

          • Neoliberal could be applicable in the sense that it mandates buying insurance and then makes insurance affordable via subsidies and regulation (rather than just tanking the industry and going with some form of single payer)

            I’m going to push back against this and hard (as you’ll see elsewhere). Just because it incorporates a market mechanism doesn’t make it neoliberal. It ramps up regulation to really extreme heights. Restricting medical loss ratio to at least 80% is striking…it’s a *cap on possible profit*. Risk corridors and other subsidies to insurance companies (as well as to consumers) are there precisely because pure market mechanisms aren’t trustworthy (hell, the mandate is part of that too! the three legged stool is designed to combat fundamental market failures).

            I mean, you might as well say that single payer is neoliberal because it doesn’t nationalise provision of care. They way market mechanisms get into the ACA are a combination of path dependance, politics, and a “we’re throwing everything else at cost control, why not a bit of insurance company action as well”.

            • tsam100

              I was careful to say that it “could be” interpreted that way. Honestly, I think the whole idea of trying to classify this law, which has hundreds of components, a pretty silly game, and I’m really pissed that we have to fight what passes for a “left” about it. The evidence that it’s helping millions of people isn’t questionable in the least, so who gives a fat fuck if it’s neoliberal or communist or a Rotary Club project?

              • I was careful to say that it “could be” interpreted that way.

                Oh sure. But I don’t think it reasonably can, analytically. And I agree that politically it is equally stupid.

                If you want a neoliberal plan look at the Heritage one. But it’s not the mandate that makes it so. Indeed, the mandate is the least neoliberal bit there! They only include it to get to a nominal form of universality which they think is inevitable.

          • Sharon1W

            Once your income disqualifies you for subsidies, and you hit your late 40s, the exchange Silver plans become very pricey. I’ve got employer coverage, but I priced a plan for me and my partner on the Maryland exchange, our household income is in the mid-90s, were both 50+ and we were looking at $1,300 a month for a mid-range plan that would cover our pre-existings. That’s just the premium.

            The ACA is a great first step, but the subsides have to cover more of the big city middle class.

            Pppppp

            • This is very true. Technically this is really an easy fix (some combination of extending subsidies, strengthening the mandate, etc.). Politically…tough.

            • tsam100

              No argument from me. We can always do more and better, and that includes all the other safety net programs.

            • Chet Murthy

              Sharon1W, I ran some (infantile) numbers: healthcare is ostensibly 10% of the median American’s household income. So you should be looking at a further $6k subsidy, if the system were working … “correctly”.

              To be clear: I’m agreeing with you. Your premium is outrageously high by … 50%?

      • Joe Paulson

        “Neoliberal” sounds like one of those plastic terms that can bring in most anything.

        Just think of Medicaid as a sort of subsidy to bring down insurance costs to zero for those unable to pay any more (NY had something in the first few years where the subsidy would lead to a monthly insurance cost of around $1). And, the for profit insurance companies still cover the people (if paid in the long run by the government) while paying for profit health providers.

      • A large number of those who should have been insured under ACA but aren’t are the 10 million who were expected in 2014 to be added to the number insured by employers, thanks to the employer mandate, the least publicly noted provision of the ACA and the one most deeply hateful to Republicans (the main purpose of that 1989 Heritage Foundation proposal was to dismantle employer-provided insurance altogether, with tax penalties, and put the entire population on an individual mandate).

        But as of last January, the employer mandate had never really been enforced. Now it’s unlikely it will be, I guess.

    • I would argue that the Heritage plan is neoliberal in the classic sense and a logical if outlier position for Reagan inspired Republicans.

      It identified two problems:
      1) medical inflation
      2) the lack of universality (which might lead to the threat of expansion of medicare, medicaid, or, in general, leading to a European style system)

      Its solution to the first is “deregulation” and “consumer choice driven by patients shouldering all non-catastrophic costs”.

      Its solution to the second is redirecting all current spending (employer tax incentives, medicare premiums and subsidies,etc.) into tax breaks and vouchers, plus a mandate.

      The analysis of other universal systems is basically “waiting times plus subsidies == bad” without any acknowledgement that putting people on the hook for most medical cost means delaying or avoiding care. (They DO acknowledge this as they believe people with get less care and that a major driver of inflation is consumer driven unnecessary care.)

      For me, if you deny Arrow’s healthcare insight and think that the problem with the US is “not enough market” that’s classic neoliberalism in strict an analogy with rejecting Keynes.

      Gruber definitely isn’t working in that paradigm at all

      • Yestobesure

        Informative answer but here’s 2 follow-ups:
        1) where does keynes fit in, and how is neoliberalism a rejection of keynes?
        2) in that case, what would your name for the Gruber paradigm be?

        Also like your comment below about how not everything with a market mechanism is neoliberal, and that the ACA regulation of insurers runs counter to the deregulating instinct of neoliberalism.

        Personally, I love the idea of standardizing products in a case where quality is opaque to consumers. I also love the idea of keeping insurers honest by capping potential profits (and symmetrically reinsuring losses to limit risk aversion). Some markets just cry out for intervention, and this is clearly one.

        • 1) where does keynes fit in, and how is neoliberalism a rejection of keynes?

          “Neoliberalism” is a complex and contested term, but I think wikipedia’s overview is reasonable:

          Neoliberalism (neo-liberalism)[1] refers primarily to the 20th-century resurgence of 19th-century ideas associated with laissez-faire economic liberalism.[2]:7 These include extensive economic liberalization policies such as privatization, fiscal austerity, deregulation, unrestricted free trade,[3] and reductions in government spending in order to increase the role of the private sector in the economy and society.[11] These market-based ideas and the policies they inspired constitute a paradigm shift away from the post-war Keynesian consensus which lasted from 1945 to 1980.[12][13]

          I associate it strongly with the Reagan revolution and its aftermath (though it was used earlier). Trickle down economics, rampart deregulation, coupled with the believe that market mechanisms will achieve arbitrarily specified good outcomes. (Contrast with libertarianism which thinks the outcomes are acceptable regardless of how awful they are.)

          2) in that case, what would your name for the Gruber paradigm be?

          Technocratic welfare/welfare state liberalism. (Where “welfare” doesn’t refer to War on Poverty style welfare programs per se, but welfare maximisation with appropriate distribution.)

          Some markets just cry out for intervention, and this is clearly one.

          And this is counter neoliberalism as I understand it. I think you can think some regulations are bad or counterproductive without being neoliberal as well. I mean, that’s just reality!

          • Yestobesure

            Appreciate this. I would quibble with the definition of “keynesian consensus”, as Keynesianism seems more inclined to macro intervention than micro intervention, and only opposes procyclical fiscal austerity, not balanced budgets per se. Of course Reagan himself ran procyclical deficits.
            Main reason I asked my original question was not so much to pick an arbitrary label for ACA but to clarify terms. The brits would definitely consider Thatcher neoliberal, and define the movement as one that didn’t give a shit about promoting welfare goals thru mkt means, but rather thought national greatness and the lot of those at the top should be improved be rolling back redistribution and regulation. In the US, it has come to mean “mkt friendly, or mkt aware Democrat”… and to some extent I think the middle income parts of the ACA fit the bill.

            • Aaron Morrow

              The “middle income parts of the ACA” added on more regulation to the preexisting system, so it wasn’t neoliberal.

            • Yeah, we need to be clear on the difference between:

              1) A policy is straighfowardly neoliberal.
              2) A policy moves the policy landscape toward a neoliberal policy or away from neoliberal policy (that policy may itself be substantively neoliberal or not).

              So the ACA is not, itself, neoliberal, afaict. It’s core theory is that healthcare markets per se don’t work, so if you are going to have market mechanisms they have to be superregulated, and subsidized, and managed, and have backstops. The ACA + public option is a better such policy because it handles market problems that we’re seeing. Market mechanism aren’t the driving feature of…almost anything.

              The move to the ACA in the US is unequestionably not a neoliberal move. We’re going from a highly unregulated situation with horrific companies screwing customers and failing to meet minimal social goals to a highly regulated situation that advances social goals on many fronts.

              Moving from the NHS to an ACA style system would be a neoliberal revolution.

          • rampart deregulation

            I dunno, according to the song you’re supposed to keep a pretty close eye on them.

      • paul1970

        One reasonable definition of “neoliberal” is the belief that problems that might have traditionally been solved direct government action could instead be solved by (potentially regulated) markets. If someone proposed the ACA as a successor to Britain’s NHS, that would be unquestionably a neoliberal act IMO.
        But in the U.S. context, it was an small step towards socialisation, and proposed, in part, due to political constraints on larger steps. Calling it neoliberal might be technically correct, but it’s not very enlightening.

        • One reasonable definition of “neoliberal” is the belief that problems that might have traditionally been solved direct government action could instead be solved by (potentially regulated) markets.

          But that’s pretty vacuous, right? I mean, I think postal delivery could be solved by potentially regulate markets. I just think in most cases it’s unwise and pointless.

          You need to be somewhat sensitive to the content of the regulations and the sorts of problem they think that they can tackle when attributing neoliberalism.

          (I agree entirely with the “directional” analysis of a particular move.)

          • Yestobesure

            ”I mean, I think postal delivery could be solved by potentially regulate markets.”
            See FedEx? Also lots of countries have privatized national mail systems (not necessarily with any real point).

            • Exactly. But that I acknowledge this fact doesn’t make me neoliberal :)

              FedEx relies heavily on the post office ;) Which is fine! It’s workable.

              Cameron privatising the Royal Mail sure seems like a neoliberal move both in trajectory and in goal (I’m pretty sure).

      • CPPB

        I think your point about the Heritage plan being a “logical if outlier position for Reagan inspired Republicans” is crucial to understanding the narrative that “the ACA is a conservative health reform plan.” As you and Scott point out, this narrative is driven by bad faith from the right, but it is exacerbated/enabled by the tiny degree of truth that (the non-Medicaid portions of) the ACA are probably the “most conservative” means of achieving a significant expansion of health care access to non-wealthy people. It’s just that significantly expanding access to health care for non-wealthy people is not compatible with conservative philosophy, so “the most conservative” means of doing it is actually very liberal relative to the status quo.

        In other words, if the Heritage plan was actually a good faith attempt to solve the problems of medical inflation and non-universality while accepting as little market intervention/redistribution as possible, it would probably have looked a lot like the ACA, right? Any other solution – whether single-payer, hybrid, or nationalization – would be even more antithetical to conservative ideology. But, of course, no one on the right actually wants to expand health care access for non-wealthy people so any amount of redistribution is too much.

        • In other words, if the Heritage plan was actually a good faith attempt to solve the problems of medical inflation and non-universality while accepting as little market intervention/redistribution as possible, it would probably have looked a lot like the ACA, right?

          It’s hard to imagine a good faith conservative plan here :) But if they concede that universality means universal quality coverage (i.e., robust essential coverage, reasonable co-pays, etc.) then it’s hard to see where else they would go.

    • McAllen

      I suppose it could be called neoliberal, but it was less neoliberal than the status quo, and was probably the least neoliberal bill that could be passed in 2010 with that Congress.

    • Scott Lemieux

      No. It would be neoliberal if the baseline was European style comprehensive insurance. In the American context, it involved a substantial increase in regulation and public expenditure. That’s liberal, not neoliberal.

      • Yestobesure

        So what distinguishes “neoliberal” from “conservative”? Or are they interchangeable when it comes to economics?

        • JKTH

          There’s no distinction other than it’s neoliberal when Democrats do it and conservative when Republicans do it. That’s part of why I find little use for the term in the US context.

          • Joe Paulson

            I think there is some objective criteria but the whole thing does seem a matter of scale. So, Scott says “substantial increase in regulation and public expenditure” makes it liberal in our case.

            But, the whole thing is still in a key way tied to the market, which sounds “neo-liberal” in some fashion, looking at the Wiki article cited elsewhere. Markets are regulated. Even those on Medicaid choose a private insurer (paid by government) and pay private doctors.

            Maybe, I’m misstating things. These terms do confuse me some.

            • Neoliberals want *unregulated* or *minimally regulated* markets and think that such markets will achieve substantial social goals.

              Obviously once you let “markets” or “regulations” in, it becomes a fuzzy line drawing exercise. But if we look at classic EU welfare states, we see systems that are on the non-neoliberal side of things (generally; EU austerity was a rank exception).

        • Rob in CT

          Hows this:

          The ACA moved the existing system leftward, while still retaining certain neoliberal features.

    • mongolia

      instead of trying to come up with the ideological underpinnings of the various parts of the ppaca, it’s honestly easier just to think of it as “what democratic leadership could get through with a dem house, a barely-60-vote dem senate, and a dem president that they felt would lead to universal health care.” thinking of the ppaca as ideologically coherent is in my opinion a fools errand, since the various path dependencies in the 100+ year history of the health care industry, governments role in health care during that time, and the pro-rural bias in the structure of american were all vital to how the ppaca was structrued.

  • Rob in CT

    3.8% additional tax on investment income and .9% additional Medicaid tax for rich people. Oh, and the money is used to subsidize health insurance for the poor/near poor.
    That’s pretty much the ballgame. Sure, there are other issues (regulating health insurers, the employer mandate, birth control coverage, subsidy phaseout issues for middle class people), but taxes on rich people used to give nice things to poor people is enough to make them hate it.

    • That’s why I was shocked when McConnell allowed the 3.8% surtax to remain on the later drafts. I mean, it’s obvious they’d put it back in in conference, since that 3.8% tax is itself is the ballgame for them..

      • Drew

        Even without conference I guess he figured passing a deeply compromised (by Republican standards) bill that doesn’t even do what they really want is better than nothing. Just ram something, anything through and say you kept your promise to kill Obamacare. I’m surprised they didn’t just try to pass a bill renaming a post office. Just name that bill “Trumpcare and by the way Obama is black” and boom. You passed Trumpcare. “But that bill just renames a post office.” “FAKE NEWS!”

  • DJ

    In yesterday’s McConnell thread, for example, multiple people said that actually McConnell is incompetent because if he knew what he was doing rather than pursuing a long-odds battle to inflict major damage to the ACA, he should have just passed a bipartisan bill to stabilize the exchanges…

    I resemble that remark!

    But seriously, thank you for focusing on the fact that the ACA is not a “Republican” plan, but is in fact the latest extension of the New Deal. I have made this erroneous argument in the past, and won’t again (even if I’m right about McConnell’s incompetence!).

  • Denverite

    The ACA essentially consisted of:

    A historic expansion of the public insurance program for the poor
    Increased taxes on the wealthy
    Substantially increased regulation of the insurance industry
    Subsidies to allow the non-affluent to purchase comprehensive insurance

    You left out that it has a host of measures intended to reduce the growth rate of health care costs. ACOs, capitated payments, etc. But most of those result in health care providers getting paid less, so Republicans will hate them too.

    • Rob in CT

      Thanks for mentioning that. There was actual healthcare reform in there, not just health insurance reform.

    • Including meaningful use and other electronic modernisation, accountable care, etc.

      Arguably co-pay free essential care is a cost control measure.

      • Denverite

        Arguably co-pay free essential care is a cost control measure.

        Depends what you’re talking about. Some sorts of routine care save money by catching expensive conditions before they get that way. Others cost money by catching expensive conditions that would kill you quickly (and relatively cheaply) if left untreated.

        • True, but if you look at the mix it’s weighted toward prevention:
          https://www.healthcare.gov/preventive-care-adults/

          Not all of it is cost savings, nor is the case that we should design for cost savings solely, but a good chunk of those cost a lot more (and include a lot of suffering) at the population level without aggressive preventative or screening measures (as far as we currently know).

          • Denverite

            Oh sure. I’m just trying to correct the “preventative care always saves money” shibboleth that you (not “you,” one) hear from time to time. Sometimes it does. Sometimes it doesn’t (but it certainly prevents a lot of suffering and unnecessary deaths). For example, on the list you link, I’d guess that the following increase health care costs on the aggregate: cholesterol screening, colorectal cancer screening, depression screening, and lung cancer screening. I’d actually think that tobacco screening and cessation probably costs society more money in the abstract because smokers tend to die early and cheaply — the ten years it cuts off your life is an expensive decade, health cost-wise.

            None of this is to remotely suggest that all of that preventative care isn’t worthwhile.

            • Pat

              Don’t forget high-blood pressure and diabetes screening as tools to reduce incidence of stroke, cardiac disease and Alzheimers.

              • Denverite

                Right. I left those off of the “probably more expensive in the aggregate” list. Diabetes screening especially can prevent or delay a very expensive condition that goes on for decades. High blood pressure screening is a little more arguable (strokes and heart attacks kill you relatively cheaply), but even then, untreated high blood pressure can cause kidney failure and Alzheimer’s, and those are expensive, long-term conditions.

                • Deborah Bender

                  If you are talking about a regular blood pressure check with the cuff, it takes two minutes and every doctor’s office has the equipment. One of the offices I go to, a medical assistant checks my blood pressure every time I visit for any reason. That doesn’t seem like an expensive test.

                  For a while, one of the chain pharmacies I use had a free robot blood pressure tester you could use while you were waiting, not much more trouble than stepping on a scale.

                • Denverite

                  The big cost with HBP screening is not the cost of screening, it’s the cost of treatment if they diagnose you as hypertensive. That entails lifelong medication and a doctor visit with blood tests at least once a year (and some docs want to see you every six months). In the absence of that screening, many people would forego all of that care until they dropped of a stroke or heart attack in their late 40s to early 60s. That’s a big cost savings (note: yes, the end-of-life care would cost something, but heart attack/stroke deaths are relatively cheap, and in any event, almost everyone has to pay for whatever kills them eventually — and in this case, given the rate of medical inflation, paying those costs sooner rather than later probably saves money as well).

                  But, like I said, HBP also causes people to have kidney failure (which is exorbitantly expensive to treat) and Alzheimer’s (less so but still pretty expensive), so I’d suspect that screening probably does save money in the aggregate. It’s just less cut-and-dry as something like diabetes screening.

                • Deborah Bender

                  Thanks for the explanation.

        • Yestobesure

          Keeping members of society alive and contributing (whether through work or as family/community members) is generally cost effective for society, even if the medical cost side of the ledger is negative.

          • The classic line is “An ounce of prevention is worth a pound of cure”. That is, early treatment is generally cheaper and more effective.

            Denverite is pointing out that this might not be true on a lifetime cost basis, if only because dying young tends to make your lifetime medical costs cheaper. This is esp true of elderly people.

            You’re pointing out that we have to look at *net* costs which complicate it.

            I’d personally look at QALY (quality-adjusted life year) cost when thinking about overall cost. But it’s true that “local savings” (over a disease course) might not yield global savings.

            • Yestobesure

              If a whole bunch of Americans dropped dead tomorrow, that would save medical costs but hurt our economy and society. That’s my only point. Of course early intervention is great when it reduces medical spending; it’s also great when it does not.

              ETA Granted, it depends which Americans…

              • Right, but my initial post was that free coverage of preventative services was a cost control measure. I still think they are, on balance, but, as Denverite points out, they might not work out that way. Of course, this is true for a lot of cost control measures! And, of course, cost control isn’t the only reason for funding preventative care.

                Consider birth control. A lifetime supply of birth control is probably cheaper than an even easy pregnancy. But most people who use birth control at one stage of their life end up having children! Delaying childbirth can make the pregnancies more expensive. OTOH, earlier childbirth probably hurts your lifetime earnings. Etc. :)

    • Scott Lemieux

      Good point.

  • sk7326

    I noted this in the McConnell thread – I once asked David Atkins on twitter why all this bailout talk of the ACA never includes the Medicaid expansion. He replied that the expansion is a separate matter. NO IT’S NOT. It’s the same mickey-ficking initiative. The only part that was remotely conservative was the notion that people had to buy insurance from a for-profit company. But that was a rather small part of the entire deal! (important, but small)

    I suspect since the exchanges are the places where most middle class and better folks interact with the ACA, that became the only thing that gets discussed. It’s something which infects the entire debate.

    • sibusisodan

      Exactly this. It’s been a slow road to change my mental model of the ACA from ‘EXCHANGES! plus mumble mumble Medicaid’ to a more accurate ‘MASSIVE MEDICAID EXPANSION! plus regulating of exchanges’.

      How did the Medicaid expansion go (for the expansion States)? Did more or fewer people sign up? Has Medicaid been meeting cost predictions? Did the websites work?

      I’m sure that answers are available if I dig. But they are nowhere near as much part of the conversation as the Exchange stuff is.

      • Exactly this. It’s been a slow road to change my mental model of the ACA from ‘EXCHANGES! plus mumble mumble Medicaid’ to a more accurate ‘MASSIVE MEDICAID EXPANSION! plus regulating of exchanges’.

        This is an overcorrection. The exchanges are a fundamental overthrow of the pre-ACA individual insurance market and cover millions of people. In lots of places they work extremely well.

        I helped family find coverage on the individual market pre ACA and it really was catastrophic coverage or bust. Recissions were common! Being essentially barred from the insurance market was common.

        • sibusisodan

          I slouch corrected!

          • Pat

            The subsidies have been hugely helpful for a lot of people who own homes but don’t work at high-paying jobs with insurance.

        • Drew

          Yup. I had a very expensive exchange plan last year. I grumbled about the high deductible and coinsurances, and not being able to get/buy into Medicaid but it was fucking infinitely better than the status quo ante. Especially for someone like me who has had suspicious moles biopsied (I’m fine but I shudder to think about what my situation would be pre-ACA).

          • Indeed! The infuriating thing is this is all pretty easily fixable. It wouldn’t even be that expensive.

    • SatanicPanic

      Was this fellow able to explain how in the heck is it a separate matter?

    • Murc

      You might be able to build a coherent argument that just because Medicaid expansion was in the same omnibus health care reform bill as other things, it isn’t necessarily of a piece with those things. Like, when Congress passes one of their mammoth appropriations bills, we don’t say that every single thing it funds is part of the same initiative despite being part of the same piece of legislation.

      I know a few people who are all “sure, the Medicaid expansion is great, but Medicaid was an already-existing program that they didn’t actually change much beyond expanding it and shoveling in a ton more money. That’s a good thing, but it could easily have been done in a separate bill, as opposed to the parts that dramatically overhauled how people who don’t qualify for the program buy insurance and how that insurance is regulated.”

      I’m not saying this is necessarily right, but it seems like it isn’t necessarily idiotic and it makes me wonder how you can couple and uncouple things from each other and what forms of that are substantive as opposed to just optical. Like, if you uncoupled the Medicaid expansion from the Affordable Care Act in a separate bill, while keeping all policy exactly the same, I think a lot more people would consider it much more separate, tho related. Because the Medicaid expansion could function and work separately no problem even if we returned to the pre-ACA status quo.

      Whereas if you, for some reason, broke other parts of the ACA into separate bills (say, one bill creating the exchanges, and another creating the subsidies, and another levying the taxes) we wouldn’t consider it substantively separate at all, because all those pieces HAVE TO work together to add up to a coherent policy initiative regardless of if they’re one bill or a hundred bills.

      I’m not sure if either of the above scenarios are right, but I’m also not sure they’re wrong. The line between substance and perception can get pretty thin.

      Having said all that: I like David Atkins a lot. But he sometimes dives off the deep end when it comes to philosophy and rhetoric. I don’t judge him for this, because I do the same thing, but it’s a thing to watch out for.

      • sk7326

        The Medicaid expansion is a big part of the “affordable” part of the ACA – and a lot of the problems with exchanges in red country are directly related to not having extra Medicaid to pick up slack.

      • Deborah Bender

        Structurally I think Medicaid could be separated out, but politically not, for the same reason Social Security isn’t means tested. If you put a lot more tax dollars into the Medicaid program and expand eligibility, but you don’t do anything at all to help people who just above the cutoff line for Medicaid, those people are going to resent the hell out of what you did.

      • stepped pyramids

        The mandate/exchange portion of the ACA only makes sense in context of the Medicaid expansion, though. The income ranges for getting subsidies on the exchange were set with the expectation that the bottom end meets the top end of the expansion. (Always worth saying: fuck John Roberts.)

      • Pat

        Medicaid pays providers a lot less than private insurance does. A simple Medicaid expansion on its own, without guidance on cost containment, would have been highly problematic for rural hospitals and other providers.

        Many people don’t know that such hospitals were previously applying to a federal government fund to help pay for critical care for the uninsured. This was possible because the federal government mandated that hospitals treat everyone regardless of their ability to pay. With the ACA, that fund has been eliminated. So pre-ACA, a hospital could treat an uninsured patient for a heart attack, say, and when they couldn’t pay, apply for payment from the feds.

  • On important point is that the Heritage plan and various summaries of it *dissemble*…you have to get deep into the weeks to find what they are really up to. If you read the summary document and see stuff like every household must have adequate insurance coverage…it’s reasonable to think that this is very ACA like. You have to sort through several distinct chapters to find out that “adequate” means “catestrophic” and that they want to repeal state mandated minimal benefits and that high premiums and copays are a *feature* not a bug.

    I’ve trusted Scott’s table since he first posted it, but the other day I decided to look for the specific quotes to back it up. I deleted a long comment because my first attempts to back up the table failed. I had to read large swaths of the actual plan document to validate Scott’s work (not that I didn’t trust you, Scott! but I wanted quotes).

    It’s a deeply sleazy piece of work at every level. People with a good plan don’t need to lie so deeply and widely about it.

  • The Heritage plan was a parody of a healthcare plan. It was an insult to actual plans. And yet it gets held up as a serious point of comparison with the ACA. I partly blame Obama for trying to be magnanimous with the Republicans, but the rank dishonesty by leftier-than-thous about a good law disgusts me.

  • Lot_49

    One of the best things ACA did was force insurance companies to offer identical products (“Bronze,” “Silver” plans, etc). Trying to figure out which plans cover what is a nightmare, because the insurance companies didn’t want to compete on price.

  • NobodySpecial

    There were really three types of complaints about the ACA process that people keep conflating.

    One was the quite logical idea that we were wasting our time holding out for that magic Republican vote that would make it fig-leaf ‘bipartisan’, and that we were doing real damage to the bill by leaving it in the hands of folks such as Max Baucus to do the heavy lifting, because they’d overcorrect to the conservative side. It also didn’t help that Kennedy, who would have been a reliable vote, died during that process and was replaced with a solid no vote.

    One was the slightly less logical, but still reasonable idea that we should have started asking for a whole loaf despite what we were told was the unreasonableness of it all instead of asking for half a loaf which then became a quarter in negotiations. Even Kennedy’s ‘Medicare for All’ plan would have been a good, simple, easily communicated starting point that people wouldn’t have instantly rejected.

    The last, of course, was the outright ratfuckery of the Hillary is 44 assholes, who were never Democrats except in name only, and were there only to maximize splits in the coalition.

    • Hogan

      It was “left” to Max Baucus because he was chair of the Senate Finance Committee, where the bill had to originate. And they didn’t have much of anything to threaten him with.

    • Rob in CT

      It does seem totally clear in hindsight that seeking GOP votes was foolish (full disclosure: I was naïve enough at the time to be surprised by how that went, but learned quickly).
      But I don’t think the political calculation behind seeking those votes was entirely stupid. First, if the Dems hadn’t tried at all, our glorious liberal media would’ve run story after story about how arrogant they were being (yes, the RW Wurlitzer ran those anyway, but I’m talking about the rest of the media). So at least some effort had to be made, IMO, for “optics.”

      And if they *had* gotten a few GOP votes, the law would’ve been “bipartisan” and would’ve put its opponents in a tougher position (downside: the law would’ve been not as good, because, um, Republicans). McConnell understood this, and made damn sure there were no “Republican fingerprints,” as he put it, on the law. Instead of thinking that getting utterly creamed in two wave elections meant his party should moderate, he stuck to his guns, and it was the right call.

      GOP votes were chased for far too long, no question.

    • Joe Paulson

      Obama ran on being able to look past “red” and “blue” etc. (it was his big maiden speech in 2004), so yes, I do think they had to go through the motions of trying to get Republican support. If nothing else, there were Democratic senators who wanted that, including one or more who had major roles in the process. The committee process, e.g., was going to make Max Baucus play a major role somehow. Overall, if you were going to pass something this major, you would try at least to get bipartisan support.

      At some point, yes, that was not possible, but don’t know how much really was lost as compared to trying to get sixty votes & waiting for that small window when they had them (a four month window) to pass something. By trying, you are able now to blame Republicans even more.

      The “loaf” concern (though the size sounds exaggerated — did not simply get a ‘quarter’) is more appropriate. But, if something was simply not going to get the votes, the necessary voters here honestly probably didn’t care enough for a harder line to be practical. TBH, I did wish there was a public option vote. The last I’ll simply ignore here.

      • Rob in CT

        there were Democratic senators who wanted that

        Backed by large majorities of Dem voters. Dem voters positive view of compromise has been falling in light of what happened, but in ’09? Hell yes a majority of Dem voters, myself included, thought we could kumbaya some shit with “reasonable” Republicans. We were wrong.

        • Taylor

          Hell yes a majority of Dem voters, myself included, thought we could kumbaya some shit with “reasonable” Republicans. We were wrong.

          I guess you must have been on a scientific expedition in Antartica for the duration of 2001-8.

          • Rob in CT

            I was in the process of becoming a Democrat during that time (by ’04 I was a Kerry voter and by ’06 I was registered Dem and voting in primaries). The Dubya era opened my eyes a fair way, but not all the way. The Obama era opened them some more.

            I didn’t think Republicans were suddenly going to become liberals, but I *did* think a party that took that kind of shellacking would moderate. I was wrong, I admit it.

    • mongolia

      One was the quite logical idea that we were wasting our time holding out for that magic Republican vote that would make it fig-leaf ‘bipartisan’, and that we were doing real damage to the bill by leaving it in the hands of folks such as Max Baucus to do the heavy lifting, because they’d overcorrect to the conservative side. It also didn’t help that Kennedy, who would have been a reliable vote, died during that process and was replaced with a solid no vote.

      a lot of the sort of bipartisan fig-leaf talk was necessary not because of the possibility of getting r’s on board, but more because the blue dog votes from deep-red states necessary for passing the ppaca needed to warm up to passing a vote on a party-line basis. remember, this is a caucus that included and *needed* every one of baucus, nelson, bayh, lieberman (not from a blue state, but christ what an asshole), specter (purple stater who flipped parties), mccaskill, tester, conrad – doing the bipartisan thing was likely necessary to allay their concerns of passing a bill that was too “partisan” and “liberal”

  • nominal

    Absolutely right.

    Times have changed since 2008, though. In 2008 I think there was a benefit to saying the ACA was just a slightly-reworked Republican health care idea. There were a bunch of moderate Democrats who didn’t want to look like communists destroying the free market and a handful of possibly-convertible Republicans. In 2008 the margins at least arguably could be persuaded that the ACA wasn’t a radical change it had lots of Republican ideas. And most importantly the Sunday pundits liked the idea of bi-partisanship, and given universal Republican opposition it was at least rhetorically helpful to position this as a “bipartisan” idea.

    Those days are over. There’s nothing to be gained now by positioning the ACA as a warmed-over Republican plan now. Or at least very little.

    Going back to 2008, though, it’s not Obama’s fault that the hard left was too stupid to realize the difference between rhetoric and truth. The Republicans never have that problem. They know that Ryan’s just laying out a line of BS and in the end will deliver slaps to the poor and lower taxes. But we have supposed supporters who will be persuaded by Jill Stein’s “Both Siderism.”

    • JMP

      There wouldn’t be much of a benefit to saying anything about the ACA in 2008, as the ACA didn’t exist yet, we just had at the end of the year had a new President-elect yet to take office who had promised to enact health care reform without all that many details.

      • Micheál Keane

        Aside from the mandate, the ACA is not terribly different than what Obama proposed during the primaries.

  • The mystery is why so many smart people adamantly refuse to listen to them.

    multiple reasons.

    two of which are:

    1. painting Republicans as hypocrites is fun. being able to say “you liked it when Heritage proposed it” is tempting. i fell into this one for a long time.

    2. painting Democrats as sellout, neoliberal, traitors-to-the-progressive-cause is fun, for some. being able to say “see, the ACA is just a Republican plan! this proves the parties are the same, therefore…. Glorious Overthrow Of Capitalism!” is a goal for those people.

    • Taj Mahalo

      Also 3. Lots of people just can’t accept that the Republican Party is, to a first approximation, the Party of Evil.

    • sanjait

      Republicans ARE hypocrites.

      It’s not just amusing to point that out, it’s true!

      How many, for example, supported the HEART Act of 1993 and then claimed that some of the same provisions in ACA were unacceptable or unconstitutional?

      • Rob in CT

        The showstopper, for me, was “Death Panels.”

  • sanjait

    This has become a “talking past each other” conversation.

    It’s right to point out the GOP’s hypocrisy in opposing the three-legged stool model of ACA.

    And not just because the Heritage Club proposed an outline of a plan in 1989, which btw was only 9 pages long and contained none of the detail necessary to make the kind of definitive conclusions about its effects that SL makes above.

    The GOP’s hypocrisy on this issue comes from the fact that a good number of Republican politicians, before Obama became president and implemented a three-legged stool system for non group insurance markets, had advocated for such a system.

    One of those was Mitt Romney, who actually implemented such a system in his state, which contained all of the four points listed in the OP. That’s a Republican doing that, and that Republican actually became the GOP’s nominee for president at the SAME TIME that GOPers were complaining that “Obamacare” was some kind of tyrannical socialism and also the same time they were arguing the individual mandate was unconstitutional.

    Further … while the GOP has always been against expansions of regulation and subsidies in practice, their rhetoric is far less consistent. They often talk about the need to cover people and help people, and often claim they will use “the market” to accomplish this, but when you get into the issue, the only way to do that is … an ACA-style three-legged stool.

    So their hypocrisy is real and is noteworthy. That’s why many people note it. It should also be noted that doesn’t make ACA identical to any Republican plan, and the differences are important, and care should be taken to avoid feeding leftier-than-thou types talking points about how ACA is a neoliberal sellout or whatever. But those latter considerations don’t erase the former.

    Also, loosely related: the ACA three-legged stool model actually IS a European style system … in that it resembles that of Switzerland.

    • Scott Lemieux

      1)The Heritage Plan was not 9 pages long. That’s the summary. Butler’s plan was a lot longer. And your charitable assessment of the handwaving requires completely ignoring the explicit structural goals of the plan (i.e. to get rid of public insurance and make most health expenditures out-of-pocket.)

      2)You vastly overemphasize the importance of the “3-legged-stool” model. It just reflects the banal observation that health insurance markets can’t work if healthy people don’t have incentives to retain coverage. Plans that are massively different can have that in common. Like, say, the Heritage Plan and the ACA.

      3)Pointing out Republican hypocrisy on the mandate had some limited value during the legal war against the ACA. Now, it’s completely counterproductive, because it implies that there’s a consensus on healthcare policy that doesn’t exist.

      4)The Krugman post you inexplicably defend didn’t just argue that the “3 legged stool framework” of the ACA was superficially similar to the Heritage Plan. He said the plans were, as a whole, largely similar. This is both clearly false and extremely pernicious.

      • sibusisodan

        In the twenty-something years since the Heritage plan, have the Republicans ever committed themselves to that amount of detail (or even length!) on healthcare?

        I can recall several sketches of outlines of possibilities released by Ryan and others. Has there been anything more substantive?

        • stepped pyramids

          There’s the HEART Act in 1993 (Chafeecare, if you will) which is kind of halfway between Heritage and ACA (plus tort reform, because of course). It was never seriously going to pass, though.

          • sanjait

            It was never going to pass, because it was a pretense for claiming to have a viable alternative to the status quote while opposing “Hillarycare”.

            But it still is pretty relevant in highlighting the GOP’s hypocrisy on healthcare. Some of the same people who voted for HEART were saying the same provisions of ACA were the death of freedom.

            • stepped pyramids

              Sure. It’s totally reasonable to respond to that by saying “in 1993 you cosponsored a bill with a mandate, why is that ‘tyranny’ now if it was OK then?” That doesn’t require arguing that the ACA was a Republican or conservative plan, nor that it’s close to the Heritage plan.

              If you agree with that, I really don’t see what all this arguing has been about. Scott and I are objecting to the “ACA is a modified Republican plan/similar to Heritage” framing, not “Republican claims about the mandate being tyrannical are hypocritical and self-serving”.

              The thing is, even if you got Republicans to concede that a mandate is an acceptable policy tool, there’s a whole bunch of other arguments they can and do use against the ACA. It contains a lot of “job-killing taxes” and “onerous regulations that drive up prices”. It’s “the government taking over 1/6th of the economy”. It contains “out-of-control spending” and is a “bailout of insurance companies”. Saint Ronaldus Magnus himself could come up through a crack from hell and officially endorse the concept of a mandate and there still would be a lot of non-hypocritical (but still shitty) reasons the GOP would have to oppose the ACA.

              • sanjait

                “If you agree with that, I really don’t see what all this arguing has been about. Scott and I are objecting to the “ACA is a modified Republican plan/similar to Heritage” framing, not “Republican claims about the mandate being tyrannical are hypocritical and self-serving”.”

                Oh, it sure seems like people object to the latter, because that’s pretty much* all I’ve ever said, and in response I see attempts to “correct” what I said as if I said something else.

                I should have just stopped at the first sentence in my OP of this thread … talking past each other. I didn’t intend it as a prediction.

                * I actually said their objections to the whole three-legged stool were hypocritical and worth highlighting, not just objections to the mandate, and that building an insurance market on a three-legged stool is IMO a completely non-trivial non-superficial non-obvious aspect of the policy design.

                • stepped pyramids

                  Well, I mean, I can’t speak for what anyone else here has been arguing with you. The original argument was about some particular claims Krugman was making. I don’t see any reason to quarrel with you and I’ll desist.

                • sanjait

                  Krugman elided some big stuff with qualifiers like “basically” and “pretty much” and “pretty close.” I’ll just leave with that acknowledgment, and then go question the life choices that led me to this moment.

      • sanjait

        1) Ok, I’m not an expert on the Heritage Plan and admittedly am not willing to dig through the archives to become one. Let’s just assume you are completely correct on all aspects of it, and I don’t doubt that is the case.

        ut the Heritage Plan isn’t the only instance of Republicans proposing a similar model. The HEART Act of 1993 is a critical example:

        http://khn.org/022310-bill-comparison/

        As is Mitt Romney’s MassCare program.

        I am ignoring the “structural goals” of the different plans, because I’m not at all arguing they are the same in those aspects. Instead I’m saying the comparisons highlight how the GOP’s outrage about aspects of ACA that so many of them were ok with previously is hypocritical, and that is noteworthy. That’s it.

        2) Yes, I think the three-legged stool aspect is important. If this is banal, then we live in a world where most people understand how this is needed to make non-group health insurance markets work, but I don’t think we live in that world.

        3) No, pointing out hypocrisy doesn’t imply consensus, necessarily. It can also imply that the hypocrite is just full of shit. That observation may too be banal to some but if polls and election results are to be believed, it is still not widely understood that Republicans talking about healthcare are full of shit.

        4) “The Krugman post you inexplicably defend didn’t just argue that the “3 legged stool framework” of the ACA was superficially similar to the Heritage Plan. He said the plans were, as a whole, largely similar. ”

        In describing their “pretty close” similarity he explicitly talks about how they both fit the three legged stool model, clearly (to me) implying that that is the basis for their declared similarity.

        And again, the three legged stool model is not superficial. It’s structural. It is the basis upon which ACA was designed to create functional non group insurance markets where most states previously had dysfunctional markets with no more than one of the legs of the stool. It’s a paradigm shift to have that, though, of course, whether it works still depends on things like sufficient funding, sufficient standards, etc.

        I can concede that Krugman here is guilty of blithely ignoring the differences between ACA and Heritage, in a way that risks feeding the misapprehensions of left-puritans.

        I’m just saying he has a point that remains true and relevant.

        • 1) Ok, I’m not an expert on the Heritage Plan and admittedly am not willing to dig through the archives to become one

          This is an extraordinary admission at the start of a doubledown when the lack of expertise including not knowing what the actual plan document was.

          This seems like a place to back down, to me. YMobviouslyV.

          4) “The Krugman post you inexplicably defend didn’t just argue that the “3 legged stool framework” of the ACA was superficially similar to the Heritage Plan. He said the plans were, as a whole, largely similar. ”

          In describing their “pretty close” similarity he explicitly talks about how they both fit the three legged stool model, clearly (to me) implying that that is the basis for their declared similarity.

          Well I have the Krugman article right here:

          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.

          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.

          Krugman doesn’t think they share all three legs!!!

          And Krugman only claims to have read the Butler puff piece, not the actual plan! The plan you can infer from the puff piece is not the same as the one you find in the actual plan!

          (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.

          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

          This is just wrong. They were trying hard to avoid any additional spending!

          Krugman read the wrong document.

          • And really, the ACA without community rating is really not the ACA. It’s like saying that the current Republican plan to replace the mandate with enrolment delays isn’t a difference that makes a difference.

            • sanjait

              Yeah, Krugman noted that difference as well. It’s a two-and-a-half legged stool.

              • Not “as well”…I’m *citing Krugman*.

                And not 2.5, one whole leg is radically different and it’s not a trivial difference.

                Plus the seat is different! Catastrophic care vs full insurance.

                • sanjait

                  Cutting off half a leg of a stool makes it radically less effective … but I can understand why my implication there wasn’t obvious before.

                  Anyway, it’s nice to see you also think that the three-legged stool aspect of a healthcare plan is not a superficial quality. Some apparently disagree with that.

                • How is it only half a leg?

                  Anyway, it’s nice to see you also think that the three-legged stool aspect of a healthcare plan is not a superficial quality

                  No, I said if you are comparing two “three legged stool” plans and one has a entirely different leg, that’s a pretty big difference in the plan!

                  “My plan for tax reform is reducing tax subsidies, stepping up enforcement, and cutting marginal rates”

                  “My plan for tax reform is increasing tax subsidies, stepping up enforcement, and cutting marginal rates”

                  Those are quite different. If you add “and it must actually be revenue neutral” they are radically different plans again.

                  I didn’t say, “And the three-legged stool aspect of a healthcare plan is not a superficial quality”. I certainly don’t think it’s determinative of a plans conservativeness, for example.

                • sanjait

                  “How is it only half a leg?”

                  If you mean ‘how is it even half a leg’, the answer is that by citing the need for high risk pools there is at least nominally an attempt to patch the gap left by a lack of guaranteed issue.

                  We could quibble about whether my half a leg metaphor is apt or not, but that too would be ridiculous.

                  And while the lack of the third leg does make a difference, my read on conservative-dom’s hyperbolic complaints about ACA was that the other two legs (mandates and subsidies) were far more prominent.

                  Beyond that, you’re arguing a lot of stuff not even in dispute. I’ll leave you to it.

                • We could quibble about whether my half a leg metaphor is apt or not, but that too would be ridiculous.

                  I certainly agree that you’re being ridiculous.

                  And while the lack of the third leg does make a difference, my read on conservative-dom’s hyperbolic complaints about ACA was that the other two legs (mandates and subsidies) were far more prominent.

                  Were there any complaints about the subsidies per se?

          • sanjait

            “This is an extraordinary admission at the start of a doubledown when the lack of expertise including not knowing what the actual plan document was.
            This seems like a place to back down, to me. YMobviouslyV.”

            I guess my point remains unclear, because I’m solely arguing that when conservative-dom for 30 years is ok with a three-legged stool model and then is suddenly outraged specifically about a three-legged stool model, that’s noteworthy for its hypocrisy.

            That I thought was Krugman’s point. That I thought was a simple point. It’s not about the intent or details of the Heritage Plan, which I have no doubt and do not dispute are fudgy and nefarious.

            Shorter: the details of Heritage plan are not at all what I was attempting to dispute, and I thought THAT was obvious.

        • Micheál Keane

          Given that “RomneyCare” passed with Democratic supermajorities that overrode every single line-item veto Romney made, have you ever considered you’ve given Romney too much credit?

          • sanjait

            I’m not even attempting to allocated credit for the MA program, I was just talking about hypocrisy. Romney signed the bill to create a very ACA-like program and then bragged about the program’s performance in ensuing years, and the GOP though he was a suitable presidential candidate at the same time it was decrying ACA in apocalyptic terms.

    • which btw was only 9 pages long

      As I pointed out in the other thread, it is 127 pages long and contains plenty of detail. I quoted extensively from it.

      Here’s that comment:
      http://disq.us/p/1kz7efb

      You’ve repeated this line several times and I think you’ve missed the counterevidence. You’ve not been arguing in light of the plan, but in light of a highly deceptive abstract of the plan. The actual plan contains the horrible details.

      • I want to emphasise again how deceptive the presentation of the Heritage plan is. The abstract is just a plain lie. Even the detailed plan dissembles a lot (putting aside the factual errors and important lacunae).

        This is a plan that claims that moving Medicare enrollees to a voucher system where it would be reasonable for them to select plans with $20k (2017 dollars) premiums.

        There’s a REASON why they tried to hide the details!

        • Rob in CT

          And I’m guessing most people who even know of “the Heritage Plan” know of the dishonest abstract…

          • Yep! And these are people who now think they “have read the plan”! Which makes countering the misconceptions ever harder.

        • sanjait

          No surprise there.

          But I don’t think evidence of dissembling should negate an allegation of hypocrisy.

          • Hypocrisy is a really boring charge. The Heritage plan was never a plank of the Republican party (certainly not in the past 15 years). So what if some think tank proposed something?

      • sanjait

        Ok, I acknowledge the existence of a longer plan, to which I was not aware before.

        But … it’s still one in a series of three-legged stool model plans from conservatives and Republicans, which makes the hyperbolic declarations of Republicans that the model is fundamentally wrong and illegal and broken, including some of the same Republicans who supported those models (!), a noteworthy bit of hypocrisy.

        I’m nowhere at all saying that makes the plans equivalent in every way to ACA, and I don’t think Krugman meant to imply that either (though his language choice left that unclear), but those conservative plans are the same as the ACA individual exchanges in their fundamental design, and the advisability and even legality of that very design remains a hotly debated.

        • But … it’s still one in a series of three-legged stool model plans

          So if a plan has three legs, we’re in? This is ridiculous.

          • sanjait

            FFS.

            IF a plan has those three legs, then it is structurally similar to another plan that has three legs, and a supporter of the first plan is a hypocrite if they denounce hyperbolically the three legs of the second plan.

            That’s it.

            What is ridiculous is … this entire conversation.

            • FFS.

              Indeed.

              IF a plan has those three legs,

              Which they don’t, here.

              What is ridiculous is … this entire conversation

              Yes, yes it is.

              I appreciate that your position keeps evolving as we lop off bits of it, but perhaps it would be easier to start with something closer to sense?

              What’s the series? Heritage, Chafee, and MA? Cf Scott how none of these were ever “Republican” plans in any meaningful sense.

            • ihops

              Christ on crutches. A three-legged stool is not a structural model; it’s a metaphor, and a goddamned reductive one at that. That the two plans share it doesn’t mean anything more substantive than that they can each slap the same piece of clip-art onto their PowerPoints.

              Conceptualizing *anything* by threes is an obvious choice. The “Rule of three” has versions in comedy, literature, and all of the visual arts. Most of the people who crafted both the Heritage Plan and the PPACA grew up in trinitarian religions. Deploying the metaphor of a “three-legged stool” doesn’t suggest anything more significant than the fact that threesomes are one of the most common patterns in the history of Western thought.

              Pick a better hill to die on.

  • paul1970

    There was also this article that headlined in The New Republic the other day (https://newrepublic.com/article/143609/new-yuppies-how-aspirational-class-expresses-status-age-inequality) that seemed sane until it casually said that people might “reasonably” think there was little difference between the two political parties because “Obamacare was originally Romneycare”. There are plenty of grounds on which it could reasonably be argued that both parties serve elite interests (trade, capital mobility, intellectual property) but to pick this supposed example, apropos of nothing, is so stupid I immediately stopped reading the rest of the article.

    • Rob in CT

      I think Scott’s point about “Romneycare” being passed by Dem supermajorities in the MA legislature is the key pushback to this.

  • sanjait

    The take home message of the Dean thing, and how other similar observers have had to flip flop on ACA in light of reality, is that cynicism can blind us.

    Sometimes cynicism protects us, because it makes us skeptical. But other times it harms us because it makes us fail to accept a good offer.

  • gwen

    It occurred to me while reading this post that there is some similarity in the Heritage-vs-Obamacare distinction as there is in the variety of “UBI” proposals.

    A couple of weeks ago Chapo Trap House had an enlightening discussion on how UBI can be either a right-wing program (replace all existing welfare programs with a single benefit to streamline and shrink government) or a left-wing program (add a UBI to enhance existing programs like Medicaid, etc).

    It seems that the Heritage Plan was a market-oriented attempt to destroy the existing safety net programs, whereas Obamacare used similar mechanisms *in addition to* expanding existing safety net programs to create a more comprehensive government health system.

    I’ve always tended to think Scott’s argument that the Heritage Plan is not Obamacare is about half-true.The distinction mainly being how the mandate/markets ideas were applied, rather than the core ideas themselves.

    The “true” part of half-true being important to keep in mind re: left-wing criticisms of Obamacare as useless, etc. Howard Dean ca. 2010 and others more recently doth complain too much.

    • sanjait

      Thank you.

    • stepped pyramids

      The problem is that you can apply this logic to a lot of other policy differences that don’t make sense. Heritage and ACA use a mandate + subsidy model to accomplish fundamentally different ends. Similarly, even the most dovish congressional Dem thinks we should have a military, but they have a much different idea about what the military should look like, how much we should spend on it, and what it should be doing than, say, Lindsay Graham. There’s a general consensus in Congress on using tax expenditures to effect desired policy goals, but what that actually looks like varies wildly.

      Not only do Heritage and ACA have different end goals and substantially different policies outside the mandate, even the immediate purpose of the mandate is different. The ACA mandate is in the law in order to make guaranteed issue viable. The Heritage mandate is in the law as an alternative to EMTALA (which was passed only a few years prior) and other programs to defray catastrophic health costs. It’s clearly stated on page 51 of the plan, which I’ve screencapped:

      https://uploads.disquscdn.com/images/e695ebc461dc887812eccc642fcdfd436c69481fba1b2b26c843e400baf7d18d.png

  • NonyNony

    I think this all sounds about right. And I want to make sure I’m clear on something from yesterday. This argument is stupid:

    multiple people said that actually McConnell is incompetent because if
    he knew what he was doing rather than pursuing a long-odds battle to
    inflict major damage to the ACA, he should have just passed a bipartisan
    bill to stabilize the exchanges or something and called it a day

    I was arguing a completely different stupid point, which is that McConnell couldn’t even get 50 of his own Republican Senators onto a bill that they could agree on. He needed to let them have more input on it – the way that Reid did with the ACA – instead of handing them a shit sandwich and telling them “vote for it or else”. In the end maybe he would have ended up with nothing because there’s no way at all to do what the Republicans have been promising their base for 7 years without taking massive political damage from it, but at least he would have had the buy-in from his own caucus and maybe could have passed something.

    • Murc

      Also too: whatever McConnell was doing HAD TO be Republican only.

      Anything that could garner the votes of, say, forty Republicans and twenty Democrats would be the kiss of death. There’d be an enormous conservative backlash.

      • NonyNony

        Right. “Reaching across the aisle to work with Democrats” on this was a non-starter. What he needed to have was something that he could call an “Obamacare repeal” and it needed to be all Republican to serve his ends.

        That’s why I’m shocked that he insisted on shutting out most of his caucus and writing the various bills without their input. He may not have needed to “moderate” the bill, and he may never have been able to get Collins or Murkowski on board because of their own reasons, but there were egos that he should have been stroking at the very least.

        • Hogan

          Was that possible in the time available?

          • NonyNony

            Their deadline was September for being able to use the hollowed-out corpse of last year’s budget bill to do this via reconciliation. Potentially they could still go for another go-round as long as they don’t pass this year’s budget bill first. So he had more time. Not time to do the full-scale wheedling that Max Baucus and Obama did, but time at least to stroke egos.

            But to be really honest – I don’t think he started even working on it until the House sent him something. I suspect he thought he could punt it and once the House passed something he’d deal with it then. The fact that the House passed a nice mess of “please do our homework for us Senators – we can’t actually figure this one out” into his lap killed that plan.

            • Hogan

              And he may even have thought that after the March House vote he was off the hook completely. Then it’s May 4 and he’s not even in the starting blocks.

        • John F

          Oh yeah, just from looking at the comments at RW sites- the majority of Americans want “bipartisanship” but a majority of GOPers do not- just the opposite, anything that a single Dem would vote for is immediately suspect to them. The mere suggestion of working with Dems enrages them.

  • Rob in CT

    OT, but I can’t help it: man I hope the recent movement in the 538 approval tracker continues:

    https://projects.fivethirtyeight.com/trump-approval-ratings/?ex_cid=rrpromo

    57.5% disapprove/37% approve, and falling.

    • John F

      Current polling movement might just be a blip- “movement conservatives” are infuriated that Obamacare was not repealed- they’ll return.

      • stepped pyramids

        Rasmussen also seems to have lost its R lean recently, possibly temporarily, possibly due to what you’re talking about.

  • the actual Bajmahal

    I guess many people who should know better, myself included, cut the repubs of the old GOP so much lack because we need to believe that our fathers were only a little bit asshole-ish, but not total pricks. This, and liquor of course, is what helps us get through the major holidays.

    • NonyNony

      we need to believe that our fathers were only a little bit asshole-ish, but not total pricks.

      Or just not outright stupid. When my dad goes into talking at me about politics these days I’m floored by just how stupid he seems to be. Like not even ideologically blind or ignorant about facts but outright “your numbers don’t add up – it’s physically impossible to do what you are talking about”.

      I’d really like to believe that Fox News killed his brain cells, but he was big into Perot back in ’92. It was tough when I came to the realization that my old man was just kind of mean-spirited to anyone who wasn’t a family member, I think it was even tougher to realize he’s actually kind of dumb too.

      • I don’t think it’s intelligence per se, it’s the fact that our cognitive systems are not optimised for certain tasks in certain circumstances. It makes it extraordinarily difficult to think correctly in adverse circumstances.

    • Drew

      Trump though is not a Republican daddy. He’s your racist uncle who you see every year at Thanksgiving dinner and gets loaded up on bud and regurgitates hate radio talking points about affirmative action blacks stealing jobs from white people and then farts loudly at the table and starts wafting it and laughing.

      • the actual Bajmahal

        Yes, that is exactly what Trump is. But I wasn’t talking about Trump and neither was this article.

        • Drew

          I know how to read, I was just supplementing your comment, not disagreeing.

          • the actual Bajmahal

            Sorry. My bad.

  • petesh

    What exactly is the point of this post? The image is of last week’s news, the first link goes to a 2010 documentary. The general discussion in re: Heritage not being the same as the ACA, merely a precursor with not enough similarity to be regarded as related (or too distant an ancestor, as some have suggested) is, in itself, an academic exercise in history. In a political context, history is for learning lessons. What is the lesson here? How does it affect the future? Can we draw on this to affect how, say, Grassley approaches improving the ACA?

    • Hogan

      The general discussion in re: Heritage not being the same as the ACA, merely a precursor with not enough similarity to be regarded as related (or too distant an ancestor, as some have suggested) is, in itself, an academic exercise in history.

      No, it’s an active political discussion. Hell, some guy named Krugman wrote a column about it just the other day. Maybe you missed it.

      • petesh

        Yes, he did, and there was a frustrating but fairly illuminating discussion of it just recently on this blog. Perhaps you recall?

        • I think it’s worth picking at. The last thread prompted me to read a good chunk of the plan, which was illuminating. I felt it there, but it was here that it crystalised for me just how much deception there was in the Heritage plan and selling of it (and not just wishful thinking). It shows how deep the lying about health care plans is embedded in the DNA of Republicans.

          I found these helpful and new.

    • sibusisodan

      Why don’t you hazard a guess as to what you think the lesson should be? That would be a better use of pixels than asking about the purpose of blog posts.

      • petesh

        The lesson I take from this history is different than the lesson I take from recapitulating it. In my view, this historical approach to discussion is worse than useless, and serves only to divide allies. Yeah, I wish Krugman hadn’t brought it up either. Since he did, I recommend ignoring his column (even though I largely agree with it).

        What I learn from the history (and it’s not a new lesson) is that every political actor, left, right, center, views both policy and process through their own lens. The most relevant fact about the ACA/Heritage comparison is not whether it’s right or wrong, it’s the fact that the perception of Republican roots (1) completely failed to attract support from the right, and (2) provided an excuse for attacks on the ACA from some on the left. (I imagine Scott largely agrees with this.)

        Claiming that the Democratic leadership lied in order to make their radical proposal seem acceptable to the mainstream is, in my view, irresponsible, indefensible, and very dangerous. It does nothing more than bolster the third-party left, which seems to have as its founding principle that the DNC, the Clintons in particular and Congressional leadership in general are lying manipulators with no goals beyond their own professional advancement.

        I do not know how best to move forward. If Grassley (et al) manage to hammer out something with Schumer (et al), that’s probably a good thing. Undoubtedly it won’t be what I want, but it could be another incremental step forward. That’s the framing I would like to see emphasized.

        • sibusisodan

          > Claiming that the Democratic leadership lied in order to make their radical proposal seem acceptable to the mainstream is, in my view, irresponsible, indefensible, and very dangerous.

          I rather think it has little to no effect at all, except to provide a tiny bit of support for the wholesome idea that we should try to view things as accurately as possible.

          The number of people who care about the difference between Democratic messaging and legislation on healthcare is…limited. The number of those who will be surprised enough by the difference to go third party is even smaller.

          • petesh

            I’m not talking about going third party, I’m hoping to recover some of those who already did.

        • Scott Lemieux

          Yeah, I wish Krugman hadn’t brought it up either. Since he did, I
          recommend ignoring his column (even though I largely agree with it).

          Shorter petsh: “It’s bad to dispute an argument that I know is wrong but I wish was right on the merits.”

  • philadelphialawyer

    “…the Republican Party secretly likes the ACA….”

    Maybe that is true in the same way the Republican Party secretly likes Roe, or the flag burning cases, or cases vindicating the rights of the accused, and so on. They like to run against them. If they went away, they would lose those hot button issues.

    One of many manifestations of the GOP’s lack of good faith, and disqualification as a real governing party, is the fact that it counts on Democrats, and, in some cases, a few “RINOS” too, in Congress, in the White House, on the Supreme Court and in other courts, and in State and local government, to nix policies, judicial doctrines, constitutional amendments, bills, etc, which it proposes, but which it knows are stupid and damaging.

    As some have mentioned, in this case, most GOP Senators and Reps now get to go back to their base and say, “Don’t blame me, I voted to REPEAL OBAMACARE!!!!!!1!!!!!111!!! Blame the Dems and the three RINOs for the fact that it still exists.” Meanwhile, no GOP Senator or Rep has to face a general electorate incensed by the real world, disastrous results that would have occurred if they had actually repealed the ACA. And so the hated Obamacare lives on, and the GOP can run against it yet again, as it did successfully in 2010, and, to some extent, in every election since then.

    • John F

      The GOP in NY absolutely loved that the death penalty had been abolished, it became their absolute number 1 primary issue for 2 decades. When they finally had the power to “restore” it, they passed this ludicrously complicated scheme that allowed them to say they restored the death penalty, spawned some litigation that allowed them to rail against soft on crime judges… and to date no one has actually been executed.

      The GOP in NY without the death penalty issue has been largely bereft, because the generic GOP package gets lot less traction here, and even NY’s GOP voters are bored by the attacks on Dems for being “Tax and Spend Liberals.”

      • EliHawk

        What’s funny is the Death Penalty went off the books again in 2004 (from activist judges on the NY Court of Appeals, no less!) and the NY GOP hasn’t won a statewide office since. That says something about the decline of crime in the state making it a less relevant issue than it was in the high crime 90s and early 90s. As it stands, the biggest people in favor of the return of NY’s Death Penalty statute were the writers of Law and Order, who could now do a half dozen ponderous death penalty cases a year featuring important RFTH debates on capital punishment.

        • John F

          Only part of the law was stricken, but it’s basically non-functional at this point.

  • John F

    “It’s really not complicated. It’s hard for them to repeal the ACA because their ideas have no mass constituency”

    No those ideas have no mass constituency, but many other GOP ideas do

  • MichaelDrew

    I generally agree with you that the ACA was a BFD – it was pretty obviously so at the time, if you just look at what it does.

    At the same time, opposing the rollback of parts of it doesn’t imply admitting that. I would oppose a random person stopping and bopping me on the nose as I walk down the street, but that wouldn’t make it a huge deal if they did it.

    Furthermore, while the 2009 status quo ante shouldn’t be dismissed as a comparison, something like an ideal system is also a legitimate standard to hold any existing system to, and it’s legitimate to think that ACA is much too close to the 2009 status quo than is desirable, or is even closer to it than it is to ideal, and to therefore reject the idea of accepting ACA as an acceptable state of affairs for any period of time, instead insisting the drive for a more ideal system must continue immediately. This is consistent not inconsistent with conceding that the step from 2009 status quo was a big deal just taken on it’s own (but one doesn’t have to take it only on its own). And since celebration is peripheral and immaterial to any of these arguments, it is not required just because one admits that the 2010 was a big deal, to celebrate it in any particular way, rather than characterizing it as inadequate.