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Problematic Left Arguments Against the PPACA I

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Ronald Dworkin is very convincing in his response to Marcia Angell’s left-critique of the PPACA. The most obvious problem with Angell’s argument is the “compared to what?” question. Her implicit point of comparison is with a single-payer system, and she (correctly) finds that the PPACA is substantially inferior. While true, the critique is also beside the point, because believing that striking down the PPACA would result in a single-payer system or anything like it is dreaming in technicolor. (It would be a major upset if Congress was even able to pass something as good as the PPACA.) As Dworkin says, to think that the Senate that even in an unusually favorable political climate wouldn’t pass even a weak public opinion or modest age reduction in Medicare eligibility would pass single payer…at that point we might as assume permanent full employment and a federal constitutional amendment guaranteeing abortion rights and same-sex marriage, because wishes are totally free. Her conterfactual justifying the faulty comparison involves the kind of wishful thinking last seen when neocons talked about Iraq:

Dworkin, like many others, dismisses a single-payer system as unrealistic, saying it would be “politically impossible in the United States now, or in the foreseeable future.” But the fact that Congress lags behind public opinion is surely partly due to liberals accepting the premise that a single-payer system is off the table…

If “single-payer is here if you want it” is your argument, you don’t have an argument. Needless to say the causal mechanism that would case the requisite number of conservative Democrats to embrace single-payer if liberals advocated really strongly for it is unspecified. It’s also worth noting that the Tinkerbell politics argument collapses on itself, because Angell also goes the implausible slippery slope route and assures us that corporate interests are so powerful that they would compel Congress to pass other “mandates” that they haven’t been able to pass in more easily corrupted state legislatures (where a commerce clause argument wouldn’t apply.) If this is true, why on earth would these powerful interests allow Congress to abolish private insurance entirely? She can’t have it both ways, and if she objects to the fact that social reform in the United States requires buying off vested interests, her complaint is with James Madison, not the Congress that passed the PPACA.

Once we get beyond the false alternative to the real argument — is the PPACA better than the status quo? — Angell doesn’t really have one. She is dismissive of the increased coverage that the PPACA offers, saying that “only 16 million people” would be covered. First, this figure requires dismissing the additional 16 million people that would benefit from increased Medicaid coverage, which doesn’t make sense, since this is part of the PPACA.  And while as a matter of formal logic the rest of the PPACA was not necessary to pass the Medicaid expansion there’s no reason to believe that it could have passed as a stand-alone measure, let alone that it could be re-passed should the Supreme Court strike down the PPACA. And second, 16 million people (“only?”) getting insurance isn’t some triviality — especially for those who live in red states — and that number of uninsured that would be covered will likely increase across time. In terms of cost controls, at both the federal level and in Massachusetts, her argument has the same problem. She’s right that the cost controls are inadequate compared to a single-payer system, but would be wrong to say the cost controls aren’t an improvement over the status quo and doesn’t even try to mount such an argument.

It’s easy to find health care policy frameworks that are superior to the PPACA, but since none of them have a chance of passing our veto-point laden system this is neither here nor there. What matters is whether the PPACA is better than the status quo, and this is a test it passes easily.  Angell is a brilliant health care analyst but it’s important for liberals to understand politics too.

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