The Lessons of the ACA

J.W. Mason, who proposed the alternative path for health care reform at Crooked Timber, has a good question:

In fact, I think the ACA makes expanding Medicare easier, simply demonstrating that large scale health care reform is possible. Compared with the status quo ante, passage of ACA is a very good thing!

On the other hand, as we all know too well, there is a finite amount of political capital available, and limited windows in which major bills can be passed. So it’s important to think critically about the full range of ways we can use those limited opportunities.

From your point of view, what can we learn from the ACA experience for the next time an expansion of the welfare state is on the table?

I think this is worth throwing out to everyone. To expand on my immediate response, I can think of a few things:

• On the most immediate point, while I wouldn’t have substituted lowering the Medicare eligibility age for the more comprehensive goals of the ACA, it remains a worthy goal in itself.  Even the expansion of our single-payer models won’t get us closer to Medicare-for-all, they’re worth doing in themselves for the reasons that were well-stated by Corey in the original post.
• There are complex lessons about federalism to be learned from the passage and implementation of the ACA.  The dark side of “states’ rights” was in stark evidence: the Supreme Court using ad hoc “reasoning” to make the Medicaid expansion less effective without creating any kind of clear standard going forward, state insurance commissions demanding autonomy to set up exchanges and then not setting up the exchanges, etc.   But it’s the system we have, and to make a particularly unoriginal argument progressive states can move the ball forward by using the ACA as a basis to experiment: single payer, public options, etc.  Showing that these policies can work is good for the state’s residents while also potentially building momentum for future federal reform.
• And, as always, the process should underscore why progressives should be cheering about the fact that the filibuster is probably on the road to oblivion, the bad things a unified Republican Congress can do notwithstanding.  I don’t want to oversell what a majority rule Senate could have done: malapportionment means that Democrats are going to have a more ideologically heterogeneous caucus when they’re the majority party, and eliminating the filibuster wouldn’t have produced single payer and may not even have produced a high-quality public option.  But the bill still could have been improved in any number of ways — with a Medicare buy-in if not a decrease in eligibility age one real possibility.   The greater leeway provided by 50%+1 would have decreased the power of a genuinely mendacious actor like Lieberman.   This lesson is, I think, perhaps imparted even more clearly by the process leading to the ARRA.  Even if effectively cutting Snowe, Collins, and the very worst Democrats out of the process wouldn’t have greatly increased the bottom-line number, and it probably wouldn’t have, it certainly would have increased the bang for the buck.   In addition, going forward, the threshold for major reforms might start in the mid-50s rather than the rare 60.

Finally, I wanted to quote from another comment in the thread from Warren Terra, about how the ACA changed the private insurance market as well as its expansion of single-payer:

2) Your claims about how the only important part of the ACA is the Medicaid expansion is but another proud boast of ignorance from you. Please to be looking up the following terms: “Rescission” “Preexisting Condition” “Lifetime Cap” “Annual Cap” and “Community Rating”.
3) Because of all those terms I listed in (2), the simple fact is that before the ACA became law the only meaningful, reliable insurance in this country (outside of Government programs like Medicare, Medicaid, and the VA) was group insurance obtained through large employers. Individual insurance was a con job – people likely to need care couldn’t get insurance, and coulnd’t afford it if they could get it, and couldn’t rely on it if that had got it – and even group insurance had most of the same caveats except when obtained as part of a very, very large group indeed.
4) So, fnck you when you say that the ACA makes it possible for people to afford a shitty policy on the individual market. In fact, it means that for the first time a policy on the individual market will be worth having; on top of that, it will be available despite pre-existing conditions, it will actually cover the needed care, and, yes, it will be subsidized if necessary.
5) As should be obvious, a health insurance system that only works for you so long as you maintain employment with a large employer that opts to offer decent benefits both sucks and blows. It left 50 million Americans with no coverage at all, and perhaps a similar number with unreliable and inadequate coverage. And the ACA destroys that restriction, and opens the door to further erosion of the tie between your employer and your health care.
6) As has been pointed out many times, including by Aimai in the comments today: the system created by the ACA has been tested for the better part of a decade in Massachusetts. It works! People are insured, and the biggest problem I’ve seen reported is that there was an initial surge of people seeing doctors for checkups, a pent-up demand that for a time stretched the available supply of GPs.
7) And, oh, yeah, those people who are getting the Medicaid benefits might feel inclined to respond unkindly to your sneering dismissal of the importance of that advance.

Again, health care is an area where relatively simple public solutions are generally preferable to more complex hybrids; no argument there. But our high-veto-point system is likely to produce a lot of complexity. So going forward — and this is why I wanted to emphasize just how different the ACA was from the Heritage Plan — it’s also important to remember that the existing private parts of the system can be made to be better or worse, and they can be regulated more of less effectively. And this isn’t just hypothetical: the Massachusetts experience shows that the basic framework can work much more effectively than the status quo ante. But the ACA isn’t the end of the struggle; in multiple ways, it’s the beginning of one.

Incremental Change: Ur Doing it Wrong

We’ve seen this crop up here, as well, but in this thread at CT several people are advocating an alternative scenario to the ACA: going for a small expansion of Medicare rather than comprehensive reform. The idea that expanding Medicare would be an incremental path towards Medicare-for-all, however, fundamentally misunderstands the dynamics of health care reform.

First of all, the version presented in LGM comments — arguing that a Medicare buy-in for 55-year-olds would be better than the ACA — is evidently horrible. Among other things, it would prefer a a modest expansion of one of our single-payers over a much more expansive extension of single-payer directed at some of the most vulnerable of American citizens. This is the kind of tradeoff that makes clear that most leftier-than-thou types aren’t really leftier-than-thou, unless thou is convinced that core progressive principles are defined by the contention that any deviation from optimal policy is the result of the unfettered will of Barack Obama.

The version presented at CT, at least, would replace the ACA with a small Medicare buy-in plus the Medicaid expansion. Here, another political problem presents itself — I just don’t think it’s plausible to think that the Medicaid expansion could have been secured except as part of a comprehensive reform package.  There’s a reason why it’s been easier for Democrats to protect Social Security than to protect the unemployed or food stamp recipients. (The Medicare buy-in has the additional problem that Joe Lieberman opposed it after he favored it; perhaps the dynamic would have changed had the Medicare buy-in been the only issue on the table, but since Lieberman was clearly determined to stick it to liberals one way or another, this is a pretty dubious assumption.) But let’s assume that Lieberman would have dropped his opposition to a Medicare buy-in and it could have passed instead of the ACA. Would this be a superior alternative because it would make Medicare-for-all more likely in the long run?

No, because — to borrow a point from Paul Starr — every time you take a relatively affluent and politically active constituency out of the employer/exchange market, you make comprehensive reform more, not less, difficult. Opposition to the ACA is strongest among those who have Medicare or are about to become eligible. This isn’t surprising: they no longer have anything to gain and potentially have things to lose. A small expansion of Medicare just increases the number of people with no stake in comprehensive health care reform, making overcoming the many vested interests to who oppose comprehensive reform even more difficult. Incidentally, another problem with the Diaz-Alvarez argument I failed to mention at the time is that it seems to assume that insurance companies are the only relevant vested interests. But this isn’t true: practitioners, who would stand to lose big if the United States adopted any kind of European model, are an even more formidable obstacle.

Indeed, if you want to do heighten-the-contradictions right, the real villain of American health care reform isn’t Barack Obama but Lyndon Baines Johnson. By taking the path of least resistance and targeting the most unprofitable customers of health insurance companies and giving a relatively politically powerful constituency no reason to support comprehensive reform, he made European-style health care reform even more difficult. Now, like most heighten-the-contradictions arguments to claim that LBJ should have forsaken Medicare out of hope that it might make Medicare-for-all more likely some day would be monstrous. Delaying Medicare would have certainly meant a lot of unnecessary suffering, and the unprecedented destruction of the American health insurance industry would have remained enormously unlikely. And depending on when Medicare happened it could have been a crappy voucher system instead of the Medicare we know today. Johnson was clearly right to take the bird in the hand rather than the magic pony in the imaginary bush, and since Johnson was a Democratic president nearly a half-century ago rather than a contemporary one I assume almost nobody would disagree. But as the fact that we’re no closer to Medicare-for-all now than we were 50 years ago makes clear, Medicare-for-some isn’t an inexorable path towards single-payer, and on net makes it even less likely.

So going for a modest Medicare buy-in instead of the ACA would have been a really bad idea. It would mean that the offer to the many of the uninsured between 18 and 55 would be “nothing” for the foreseeable future. Removing the comprehensive framework would, at the minimum, have created a substantial risk of no Medicaid expansion or an inferior one, and possibly more vulnerable to outright nullification by the Supreme Court as well. It would make the constituency for better comprehensive reform smaller and less powerful (while, on the other hand, nothing about the ACA takes future Medicare buy-ins off the table.) It’s certainly a better argument than daydream believing about how Prime Minister Obama could have gotten single payer but he DIDN’T EVEN TRY, because it’s at least tethered to some recognizable political reality, but it’s not a good one.

Thomas Jefferson School of Law slashes jobs, salaries, and budget

The new dean at TJSL has apparently been brought in to clean up the mess created by his predecessor, and he’s not being too shy about the fact:

I do not know how Thomas Jefferson became the whipping boy for critics of legal education. We must, however, be honest with ourselves; many of our troubles are the result of our own missteps, our own failure to plan, and our own failure to address problems in a timely fashion. My immediate plan and promise to you is that we will take aggressive and transparent action to confront these challenges. Since July 1, we have taken what I think are positive, though at times painful, steps to address the most critical challenges, whether self-imposed or systemic. Let me give you three examples.

First, while a general decline in enrollment is a systemic problem, we did not help the situation by allowing an unsustainable growth in the administrative structure of the school or building a facility as grand as ours. But, as you may have seen in press reports, the law school made severe cuts to its budget in response to the nationwide decline in applications. The reports did not paint the full nature of those cuts. For fiscal year 2014, the law school made cuts, totaling $4,798,081. Among other things, we layed-off 12 staff members, eliminated many more unfilled open positions, cut staff salaries by a minimum of 5%, cut faculty salaries by a minimum of 8%. In spite of these cuts, I am proud to say that 100% of the faculty contributed to this year’s annual fund.

Skimming TJSL’s tax filings for FY2012, it appears the new dean has cut the school’s operating budget by nearly 10%. As of 18 months ago TJSL’s balance sheet looked pretty shaky: the school appears to be almost 100% dependent on tuition, with a bit of rental income thrown in (if it has an endowment I can’t find it in its financials).

The school’s only significant asset is an extremely expensive and very heavily leveraged new law building: the institution’s net worth, as of 18 months ago, was equivalent to about five months of its current operating costs. Its bonds have been downgraded to junk status. (Per S&P, “management does not anticipate meeting the [school's] financial covenants until 2018.”)

Even by today’s grisly standards, employment outcomes for TJSL grads are almost unbelievably bad: a glance at its NALP report suggests that perhaps a quarter of the 2012 graduating class got real legal jobs, very loosely defined (21 of 260 graduates were reported to be making salaries of $56,750 or more nine months after graduation). Almost all these jobs were with tiny law firms (ten or fewer attorneys); only seven graduates got government positions, four as PDs and three as DAs. More than a third of the class was simply unemployed nine months after graduation.

TJSL doesn’t give out much in the way of tuition discounts, with the average student paying around 85% of the school’s $47,300 nominal sticker price (current nine-month cost of attendance is estimated at $72,000 by the school). If you include accrued interest the 98% of the 2012 graduating class with law school debt had just under $200,000 in such debt. This doesn’t include undergraduate debt (Again, the federal government will loan $216,000 over three years to anyone TJSL chooses to admit, assuming that person has not already defaulted on other loans.)

Obviously, even the most mild reform in the absurd process by which higher education in general, and post-graduate education in particular, is funded in America would put TJSL out of business immediately. (The school’s enrollment is shrinking very rapidly, with the last three first year classes featuring 440, 387, and 265 students respectively, despite moving to a quasi-open enrollment policy. While the school traditionally admitted about 45% of applicants, that number was up to 73% in 2012. And since a very large number of TJSL students transfer or flunk out after their first year, graduating classes tend to be only about two thirds the size of entering classes). Even without any reform, it may well be the first ABA law school to keel over, in which case the votaries of “the market” will undoubtedly celebrate another triumph of their mysterious god.

Religion and Reproductive Freedom at the Court

Partially in response to reader requests for handicapping of the contraceptive mandate and official prayer cases, I have thoughts on some of the cases that will come down in 2014. SPOILER: the decisions are likely to be bad because the Roberts Court is terrible.

Dam Da?

I read this article –about sneaking Vietnamese fish sauce into dishes– with interest, because learning shortcuts for how to deepen flavors in a dish is passion of mine.

A couple of years ago, I tried a “Cook’s Illustrated” recipe that promised tasty chicken pot pie in an hour and a half. One of their secrets to getting slow-simmered flavored into the pie filling was to fold in browned mushrooms and a teeny bit of soy sauce and tomato paste. You didn’t know the paste and soy sauce were there, but they were, selflessly adding a lot of flavor and taking no credit. It was a great recipe.

I also recently made a Rachel Ray umami-marinated flank steak. The marinade had stuff like anchovies, soy sauce, and sun-dried tomato paste in it. The steak was delicious.

I made a quick chicken pot pie the other night (using store-bought crusts) but forgot my flavor-boosting tricks from the last time I attempted the dish. It was good, but was absolutely missing the depth of flavor the CI secret ingredients lent.

All this has got me thinking about umami-possessing and flavor-deepening ingredients. Do you have any tricks to or techniques for lending slow-cooked flavors to quick dishes? Any flavor-boosters you swear by?

“One of the most misogynistic proposals I’ve ever seen in the Michigan Legislature”

Which, of course, didn’t stop it from being passed:

Both chambers of the Michigan legislature have passed a measure banning insurance coverage for abortion in private health plans. And because of the way the legislation was put forward, it is set to become law despite the objections of both the state’s Democratic minority and the veto of the Republican governor.

The votes Wednesday added Michigan to the eight states that already have laws restricting abortion coverage in private insurance plans, including those sold on the exchange. Women on the state’s Medicaid are already barred from using it to cover abortion except in very narrow cases.

In a charged hearing Wednesday, Michigan Senate Minority Leader Gretchen Whitmer told the story of her own rape and called the legislation “one of the most misogynistic proposals I’ve ever seen in the Michigan Legislature,” according to the Detroit Free Press. Abortion coverage will be available to women who purchase separate riders. But as Whitmer put it, “This tells women who are raped … that they should have thought ahead and bought special insurance for it.”

“The fact that rape insurance is even being discussed by this body is repulsive,” she added.

Ah, the tea party, all about freedom.