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Jacobin: Actually, Republicans Love Medicaid

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WASHINGTON, DC – JANUARY 07: Speaker of the House Paul Ryan (R-WI) (3rd L) shares a laugh with Republican members of Congress after signing legislation to repeal the Affordable Care Act, also known as Obamacare, and to cut off federal funding of Planned Parenthood during an enrollment ceremony in the Rayburn Room at the U.S. Capitol January 7, 2016 in Washington, DC. President Barack Obama has promised to veto the bill. (Photo by Chip Somodevilla/Getty Images) *** BESTPIX ***

Above: Presumably, they’re laughing because they’ve achieved Paul Ryan’s frat kegger dreams of providing subsidized insurance for poor people!

The sacred honor of the Party of Lincoln has been stained, and Seth Ackerman will have none of it!

Incidentally, it’s also why New York Magazine’s Jonathan Chait missed the point the other day…when he argued that the GOP is unique among the world’s conservative parties in opposing efforts “to subsidize medical care for those who can’t afford it themselves.”

Um, this seems…unassailably accurate?

Sure, that’s what the Republicans’ rhetoric says. But look, for example, at the eighteen, mostly deep-red states that refused to participate in the Obamacare Medicaid expansion. Since Obamacare began, the total number of Medicaid enrollees in those states has actually increased by 11 percent, from 18.6 million to 20.9 million, with fifteen of the eighteen states seeing increases and only two seeing decreases.

OK, so more than a dozen Republican state legislatures have refused to take the Medicaid expansion, leaving millions of people without insurance and leaving a huge amount of money on the table. But because…these states are mostly not shrinking, and hence more people will become eligible for Medicaid even if the (generally very stingy) eligibility standards remain the same, Republicans…actually support Medicaid expansion and their opposition is purely rhetorical? What in the living hell is talking about? Indeed, this sits at a perfect 180 degree angle from reality, which entails Republicans being rhetorically committed to providing insurance to everyone while wanting tens of millions of people to go without insurance and the insurance that most people have be made worse in practice. 

The Republicans who control those state governments could have slashed those numbers if they’d wanted to. But they don’t. What they’re most keenly opposed to — besides any policy with the name “Obama” on it — are precisely efforts to provide public health insurance to people who otherwise might be able to afford to buy private insurance of some kind.

The idea that everyone in, say, Texas — where you’re not eligible for Medicaid irrespective of income unless you’re “pregnant, a parent or relative caretaker of a dependent child(ren) under age 19, blind, have a disability or a family member in your household with a disability, or be 65 years of age or older” — can afford private insurance if they’re not on Medicaid is absolutely insane. Which is why more than 4 million people in Texas are uninsured, despite the fairly generous subsidies the ACA offers some middle class people (although, yes, not nearly generous enough towards the top of the range and public insurance would be better) to purchase insurance! Also, at least while Obama was in office, they really couldn’t have slashed those numbers and kept their federal money; you can’t turn away eligible people who sign up and presumably HHS wouldn’t have granted a waiver to reduce eligibility requirements.

Because that would be bad for business. But then, in that respect they’re not so different from Democrats, who in 2010 couldn’t stomach even a milquetoast public option open to middle-class patients. Again, those are the patients who might otherwise be purchasing private policies from private insurance companies. And, again, giving them public health insurance would be bad for business.

First of all, it’s not actually true the “Democrats” per se opposed a public option; a bill with a public option passed the House, and Obama would have signed it, but some Democrats in the legislative body that massively overrepresents rural conservatives opposed it and they all had a veto. But, that aside, again…what the hell is he talking about? Democrats passed a hugely ambitious expansion of public insurance for the poor. No Republican voted for it, four Republicans on the Supreme Court voted for it to be struck down entirely, most Republican state legislatures have rejected it, House Republicans passed a bill with savage Medicaid cuts last year, and they are openly saying they’ll try to slash Medicaid again. But their opposition is purely “rhetorical” when you think about it!

Of the many weird arguments made frequently by leftier-than-thou types, this insistence on arguing that Republicans secretly support the ACA is the one I understand the least, particularly at this late date. But if you’re strongly committed to a “both parties are the same” frame when they’re further apart than they’ve been since Reconstruction I guess you do what you have to do.

UPDATE: Chait responds himself. 

…to amplify some discussion in comments, this point from Chait is particularly important. Ackerman’s assumption that the desire to protect industry profits is the only variable that influences health care policy outcomes doesn’t explain the behavior of either party.  Republicans have repeatedly put their principles (i.e. fewer people should have insurance and the government should spend less money on it) above industry profits!

This claim is even more divorced from reality than his previous one. In the eight years since Obamacare was signed into law, Republicans have continuously taken steps that threaten insurance industry profits. Obamacare contains a series of measures to ensure the stability of the risk pool, compensating insurers who wind up with unusually sick customers. Republicans have repeatedly underminedthose provisions, either legislatively, by filing lawsuits to block the payments to insurers, or (once Trump took office) simply refusing to make them. They passed a tax cut that included a repeal of the individual mandate, the provision in Obamacare that insurers most support.

The state-level Republican crusade to deny the Medicaid expansion also hurt insurers. Medicaid wound up soaking up costly patients, freeing insurers to cover a healthier population. (Two studies found this result.) That’s why, Solomon confirmed to me, “in most states [insurers] do support expansion in my experience.” The clear and consistent pattern is one of Republicans repeatedly threatening insurers, to the point of withholding payments they were legally owed, in order to prevent poor and sick people from getting insurance. It is bizarre that Ackerman concludes that the GOP doesn’t actually care about denying insurance to the poor and sick (a goal it has in fact pursued fervently) and instead cares about profits for insurers (a goal it has in fact undermined relentlessly).

Leaving aside the self-flattery, the “I Am The Only Principled Man In America” viewpoint is both incompatible with good analysis and also completely misdiagnoses the key problems with American politics. If the Republican Party was merely venal the situation would be a lot less dire.

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