The Harper’s Story on the ACA is a Disgrace

You can pretty much discern the quality of Trudy Lieberman’s would-be takedown of the ACA from the ostensible left from the one paragraph that isn’t behind the paywall:

In July 2009, as the Affordable Care Act moved through Congress, Steny Hoyer, the second-ranking Democrat in the House of Representatives, laughed at the idea that any legislator would actually read the bill before voting on it. If such full-body immersion were necessary to support the A.C.A., he said, “I think we would have very few votes.” In March 2010, just before the law passed, speaker of the House Nancy Pelosi made a similar point. Addressing a national conference of county officials, she declared, “We have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”

Durrr, a bill restructuring the American health care industry had a lot of words in it! We’ll pretend not to know how the contemporary legislative process works! We’ll take Nancy Pelosi egregiously out of context! (Although, in fairness, Lieberman does at least include the full sentence, which if you look carefully means that she’s not arguing anything like what it’s being implied she’s arguing.)

It is, I suppose, theoretically possible that an article that leads off with talking points that have been Fox News staples for many years could still be good. I didn’t take the hint and actually read the thing, and in this case the smart money is right. Some of the argument is reasonable, if banal — health care in the U.S. remains too expensive for many individuals and is too costly in general. Inevitably, Lieberman suggests that the real winner from the ACA are health insurers, although she doesn’t explain why they spent so much money to oppose the bill that is a massive windfall. (It’s true that the ACA provides more customers for insurers; it also has regulations that make many of these customers unprofitable.) Her discussion of employer-provided insurance is replete with post hoc ergo propter hoc problems.

Since there’s a limit to how many words I’m willing to type out, though, I wanted to focus on one particularly egregious part of the article, her treatment of the Medicaid expansion. It’s obviously not a surprise that this kind of attack on the ACA would yadda-yadda the Medicaid expansion. But the way Lieberman deals with Medicaid is considerably worse than had she ignored it altogether. Here is pretty much everything she has to say:

To its credit, the law also allowed sick people to buy insurance and more of the neediest Americans to qualify for Medicaid. But in the 21 states that chose not to expand their Medicaid programs, the poorest of the poor are ineligible for ACA subsidies and, in many cases, receive no help from the regular Medicaid program.

That’s it — the next paragraph moves onto another point, with both the Medicaid expansion and guaranteed issue consigned to a two-sentence “to be sure” graf in a lengthy article. The first problem is that the description doesn’t remotely convey the magnitude of the change involved in changing Medicaid to a program that was required only to cover a fraction of the very poorest to a an entitlement for everyone within 133% of the poverty line. But even worse is that she points out the states that have not taken the Medicaid expansion while failing to mention the Supreme Court re-writing the program. Her language effectively blames Congress for not creating a backstop to the version of the bill written after the fact by John Roberts, which is remarkably dishonest. Later, she cherry-picks Tennessee as a case study for how the ACA has worked for the poor, and after describing a state in which Republican officials refused to implement the ACA’s Medicaid expansion concludes that the ACA — not the Supreme Court, not the state officials — “failed a substantial part of the population it was actually designed to help.”

This shoddy analysis leads to other problems:

Perhaps these would have been reasonable tradeoffs for truly universal coverage. But the Congressional Budget Office estimates that even under the A.C.A there will be 35 million Americans without health insurance, down from about 52 million when the law was passed…Shoshanna Sofaer of the American Institutes For Research suggested that the ACA should be held to the highest possible standard. In three to five years, she said, we would know whether the law “led to anything remotely resembling universal coverage.” But this gets to the root of the problem. Whatever the slogans suggested, the ACA was never meant to include everyone.

The reader is likely to infer that 35 million is something like the ceiling of the ACA (she doesn’t mention, for example, that the CBO data expects the number of uninsured to go down to 27 million by 2017.) But even a ceiling of 27 million uninsured assumes, inter alia, that not a single other state will take the Medicaid expansion — not even Maine or Wisconsin or Virginia. And, obviously, an ACA that worked as intended with a full expansion would, in fact, be well down the road to universal coverage.  In the kindest construction, this is a fuzzy discussion of the issue that gives the reader very little idea how many Americans will have insurance in 10 years should the the ACA survive, and the one fact it selects leaves a highly misleading impression.

There are a lot of problems with American health care despite the major improvements of the ACA, and there’s certainly a good article waiting to be written about them, putting the accomplishments and limitations of the ACA in fair perspective. Lieberman’s relentlessly tendentious assessment is not even close to being that article.