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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.

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