Arrrrrrrrrrrrrrgh please make it stop:
Republicans know all of this. They know it because the ACA is actually the conservative, market-based alternative to single-payer. It was essentially was the Heritage Foundation’s alternative to Hillary Clinton’s 1993 healthcare plan. It became the basis of Romneycare, the plan backed and enacted by the 2012 Republican nominee for president. It’s the Republican alternative to single-payer.
No no no no no no no no no no. This is all grossly misinforming readers of the Washington Monthly.
First of all, let’s be clear about what the Heritage Plan was. It was a plan to end Medicaid, Medicare, and most employer-based insurance and replace it all with threadbare, not-very-generously subsidized catastrophic plans. In other words, the Heritage Plan represents what the Freedom Caucus wants to do, and is radically different from the Affordable Care Act. The only significant similarly between the two plans is the penalty for not carrying insurance, but despite the outsize significance this feature took on because the neoconfederate constitutional case that was ginned up against the ACA focused on it doesn’t make the plans similar in any important way. The mandate was hardly some extraordinary innovation on the part of the Heritage Foundation — it just represents the banal fact that preventing death spirals in insurance markets requires some mix of carrots and sticks so that insurance pools are reasonably balanced.
Portraying what Paul Ryan would ideally like to do to the Affordable Care Act as what he’s seeking to destroy requires piling two tons of bullshit onto the phrase “based on.” How the shell game works is that you quickly shuffle from the Heritage Plan to two very different ones that are, unlike the Heritage Plan, unrepresentative of the views of national Republicans. The 1993 Chafee proposal is more like the ACA than the Heritage Plan, although it was still very different (no Medicaid expansion.) But more to the point it was a decoy proposed by a nominal Republican, and tells us exactly as much about Republican preferences on health care policy as Chafee’s proposal to enact a national ban on handguns tells us about Republican preferences on gun control. The health care bill signed by Mitt Romney is more like the ACA than the Heritage Plan, but again plans passed by supermajorities of Massachusetts Democrats tell us absolutely nothing about what health care policy national Republicans favor. The only internal battle within the Republican Party over what to do about the uninsured is about whether it should be “nothing” or “less than nothing.” You have to be gullible in the extreme to think that what they pretend they’re willing to support when there’s a chance Democrats might pass comprehensive health care reform is in any way meaningful.
The non-imaginary Heritage Plan is, in fact, a very useful guide to Republican health care policy goals. It explains why Paul Ryan has proposed to replace Medicare with a voucher system. It explains why he’s now trying to destroy Medicaid. It explains why Republicans initially wanted to fund their attack on the ACA by eliminating the tax deduction for employer-based insurance. (To be clear, there would be nothing wrong with this if the idea was to replace employer-based insurance with a combination of expanded public insurance and a more regulated and subsidized private market; needless to say, this has never been what Republicans have in mind.) It explains why Ryan thinks that the question of whether a plan reduces or increases the number of people without insurance is a “beauty contest.” To use the Heritage Plan to argue that Republicans really secretly wanted to pass something lie the Affordable Care Act is utterly perverse. And to call the ACA “conservative” is imagining a political spectrum that is rather radically different than the actually existing American one.
Unlike most of the people who repeat this epic howler, Atkins’s purpose doesn’t seem to be to describe the ACA as essentially worthless. But his claims are not true, and they’re not true in a very pernicious way — most importantly, it’s vastly too generous to Republicans. In the current context, it implies that TrumpCare is just a minor variation on the ACA. While it doesn’t go as far as the Heritage Plan would have, it would destroy the individual market in health insurance, make insurance worse in general, and effectively destroy Medicaid. Even when well-intended, flagrant untruths about the Heritage Plan and Republican health care policy preferences play right into Paul Ryan’s hands.