Is the Affordable Care Act a 'Republican' Health Plan?
December 9, 2013 9:02 AM   Subscribe

The conventional wisdom about the origins of the Affordable Care Act is that it is a reformulated plan from the Clinton era, one that right-wingers like Newt Gingrich and the Heritage Foundation created. How true is it?

As wikipedia says, "The Patient Protection and Affordable Care Act consists of a combination of measures to control healthcare costs, and an expansion of coverage through public and private insurance: broader Medicaid eligibility and Medicare coverage, and subsidized, regulated private insurance. An individual mandate coupled with subsidies for private insurance as a means for universal healthcare was considered the best way to win the support of the Senate because it had been included in prior bipartisan reform proposals. The concept goes back to at least 1989, when the conservative Heritage Foundation proposed an individual mandate as an alternative to single-payer health care.[49] It was championed for a time by conservative economists and Republican senators as a market-based approach to healthcare reform on the basis of individual responsibility and avoidance of free rider problems."


Scott Lemeiux argues that the Republican plan offered during the 90s is "radically dissimilar" from the ACA.

So what are the similarities? Turns out just the idea of buying health insurance on an exchange. Politifact calls this claim, advanced by Obama, 'mostly true'. Obama said:

"A lot of the ideas in terms of the (health insurance) exchange, just being able to pool and improve the purchasing power of individuals in the insurance market, that originated from the Heritage Foundation."

Moreover,

"We agree with Heritage that the differences between its original vision and the version enacted into law are not trivial, and are enough to undercut the president's effort to secure a Heritage Foundation seal of approval for his bill. But the president helped his case by wording his statement with extreme care. Intentionally or not, he gave himself subtle linguistic running room by saying that "a lot of the ideas" for the exchange came from Heritage, including the concept of "just being able to pool and improve the purchasing power of individuals in the insurance market." Even if not all of the ideas in the two plans are identical, we feel that it was fair of him to say that "a lot of the ideas" are in common, including the notion of pooling. So we conclude that the president's statement qualifies as Mostly True."

During the Republican debates, progressive think tank ThinkProgress tweeted: "FACT: Basis for socialist Obamacare, the individual mandate, originated with right-wing Heritage Foundation #truth"

The Wall Street Journal wrote, "Is it the #truth? Yes, but it's a little more complicated than the ThinkProgs [sic] let on."

Interestingly, conservatives have argued that the connections between ObamaCare and the Heritage health plan are tenuous. The Wall Street Journal accuses them of rewriting history.
posted by MisantropicPainforest (141 comments total) 14 users marked this as a favorite
 
Yes, the individual mandate used in the ACA is a device the conservatives were for until a Democrat wanted to use it. So the Republican party is acting like assholes and the ACA is mostly a conservative healthcare idea.

That's already well known.
posted by Brandon Blatcher at 9:07 AM on December 9, 2013 [23 favorites]


My response to Lemeiux's article is already addressed in the article:
Noting the mandate in the Heritage Plan in the context of demonstrating the ad hoc nature of the radical libertarian constitutional challengeto the ACA is fair game — the mandate was the focus of the constitutional argument, so nothing about that argument implies any substantive policy similarity between the Heritage Plan and the ACA. And even though the Heritage Plan was just a decoy, it’s still eminently fair to observe that nobody noticed that the mandate was the greatest threat to human freedom ever when it spent years as the nominal Republican alternative.
It's very relevant that an insurance mandate is a central part of both the Heritage plan and the ACA - it's the only way that the ACA can function. Conservatives often argued that you could get rid of the mandate but magically keep the parts that their constituents liked, like dependent coverage until age 26 and an end to pre-existing conditions.

It seems to me like Lemieux is responding to criticisms of the ACA that just don't really exist in any vocal majority. The majority of anti-ACA attacks from the left aren't because the ACA is perceived as a conservative plan - it's because there are serious flaws in the ACA model, something that Lemieux acknowledges.
posted by muddgirl at 9:13 AM on December 9, 2013 [13 favorites]


Yes, the individual mandate used in the ACA is a device the conservatives were for until a Democrat wanted to use it. So the Republican party is acting like assholes and the ACA is mostly a conservative healthcare idea.

That's already well known.


Could you please actually read the links? They actually say the exact opposite of what you just wrote.
posted by MisantropicPainforest at 9:15 AM on December 9, 2013 [5 favorites]


Could you please actually read the links? They actually say the exact opposite of what you just wrote.

Actually, they don't. Brandon Blatcher's comment was pretty carefully worded and is supported by the links and by reality.
posted by The World Famous at 9:19 AM on December 9, 2013 [8 favorites]


Could you please actually read the links? They actually say the exact opposite of what you just wrote.

I think this is just going to come down to "truth has a liberal bias".
posted by sideshow at 9:20 AM on December 9, 2013 [3 favorites]


heh. he said "reality". heh.
posted by quonsar II: smock fishpants and the temple of foon at 9:21 AM on December 9, 2013 [4 favorites]


Why they object to it: it's called Obamacare
Their primary contribution to it: Naming it Obamacare
posted by Artw at 9:22 AM on December 9, 2013 [83 favorites]


Lemeuix's point is that, from a liberal perspective, the Heritage plan was pretty much worse than the ACA in every way - it mandated that people buy poorly-regulated insurance from the private market while seriously damaging both Medicare and Medicaid.
posted by muddgirl at 9:23 AM on December 9, 2013 [13 favorites]


Conservatives often argued that you could get rid of the mandate but magically keep the parts that their constituents liked, like dependent coverage until age 26 and an end to pre-existing conditions.

Part of me really wanted just the mandate to die, as the resulting financial disaster in the medical insurance industry might have given rise, and rather quickly, to a single payer system.

Could you please actually read the links? They actually say the exact opposite of what you just wrote.

Perhaps if he had said that the ACA was a conservative idea, and so on and so forth, yes. But the links did seem to show that a mandate was part of the Heritage Foundation plan.
posted by Slackermagee at 9:25 AM on December 9, 2013


I thought it was repackaged Romneycare? And this whole tirade by Republicans was just, we never nominated Romney, no we didn't, la-la-la. Chief Justice Roberts didn't declare it constitutional, no he didn't.
posted by dances_with_sneetches at 9:28 AM on December 9, 2013


Could you please actually read the links? They actually say the exact opposite of what you just wrote.

Not really. First of all, Lemeiux is rebutting arguments from the left, which are completely different from those on the right. The entire "Obamacare is tyranny" line of thought essentially comes from the individual mandate. As far as I can tell, 99% of conservatives never even get past that argument, something both Lemieux and Taranto address. Here's Lemieux:
Noting the mandate in the Heritage Plan in the context of demonstrating the ad hoc nature of the radical libertarian constitutional challenge to the ACA is fair game — the mandate was the focus of the constitutional argument, so nothing about that argument implies any substantive policy similarity between the Heritage Plan and the ACA. And even though the Heritage Plan was just a decoy, it’s still eminently fair to observe that nobody noticed that the mandate was the greatest threat to human freedom ever when it spent years as the nominal Republican alternative.
And Taranto:
Heritage did put forward the idea of an individual mandate, though it predated HillaryCare by several years. We know this because we were there: In 1988-90, we were employed at Heritage as a public relations associate (a junior writer and editor), and we wrote at least one press release for a publication touting Heritage's plan for comprehensive legislation to provide universal "quality, affordable health care."
You can make the argument that things like the Medicaid and Medicare regulations are, indeed, major differences between the two, but that's a distinction lost on the vast majority of opponents on both sides. In that respect, then, it doesn't really shoot down the use of the argument that the Heritage plan and Obamacare are similar.
posted by zombieflanders at 9:29 AM on December 9, 2013 [1 favorite]


But the links did seem to show that a mandate was part of the Heritage Foundation plan.


Yes and that is the only similarity between the ACA and the Heritage plan.

As Lemeiux argues, "So, in the relevant context, the presence of a mandate in the ACA doesn’t establish any kind of fundamental similarity with the Heritage Plan. It just means that it’s universal health care reform designed by a non-moron."
posted by MisantropicPainforest at 9:29 AM on December 9, 2013


What is this, high school? Who the hell cares? Bottom line question is, can the thing work?

Given past experience of over-sized government agencies, I'm betting not. Certainly not to a country as far in debt as America is. But that's for another post, I suppose.
posted by IndigoJones at 9:31 AM on December 9, 2013 [1 favorite]


Could you please actually read the links? They actually say the exact opposite of what you just wrote.

My two cents (as someone who has followed, and lived through, this): memories are very short, and conservatives are masters of rewriting history. It's an absolute fact that Newt Gingrich, et al, were enthusiastic champions for the individual mandate and trumpeted it far and wide. They've cynically and strategically run from it since.
posted by Benny Andajetz at 9:34 AM on December 9, 2013 [1 favorite]


If a coverage mandate is the only similarity you can point out between the Heritage Plan and the ACA as written, I'd argue that doesn't really mean anything. A requirement to carry is so obviously something you'd have to have to make pre-existing condition coverage, for example, possible that it's kind of like saying one copies the other because they both involve third-party payments for health care.

(Which, by the way, has apparently become the new socialism to some doctors - mainly in Arizona obviously. If the ACA accomplished nothing more than driving doctors like this out of the medical profession, that would be more than enough reason to support it.)
posted by Naberius at 9:37 AM on December 9, 2013 [1 favorite]


Americanism is when republicans do it. Communism is when democrats do the same thing.
"Only Nixon could go to China." Because if Nixon weren't in the White House he'd be rallying against the democrats as traitors to America.
(I did read the above, with the exception of the Murdoch links)
posted by dances_with_sneetches at 9:40 AM on December 9, 2013 [3 favorites]


If a coverage mandate is the only similarity you can point out between the Heritage Plan and the ACA as written, I'd argue that doesn't really mean anything.

It means a lot when the primary opponents of the law are opposed to the mandate specifically, which they themselves had no problem with when they proposed it.
posted by jason_steakums at 9:41 AM on December 9, 2013 [13 favorites]


12 years from now if ACA is a success the Republicans will be claiming it was all their idea.
posted by COD at 9:41 AM on December 9, 2013 [4 favorites]


dances_with_sneetches:
Because if Nixon weren't in the White House he'd be rallying against the democrats as traitors to America.
I get your point, but I still find it funny you brought up Nixon.
posted by charred husk at 9:45 AM on December 9, 2013 [5 favorites]


Given past experience of over-sized government agencies, I'm betting not. Certainly not to a country as far in debt as America is. But that's for another post, I suppose.

Sure, put it together. But generally speaking, universal health care programs similar to Obamacare as implemented by Germany and Denmark have proven pretty efficient and both improving health care and reducing costs pretty much across the board. Hell, apart from the website debacle--something that has essentially already blown over--even Obamacare has largely proven to be a net positive. And considering that the other main thrust of the law was to ensure that health care costs go down, it's working pretty well:
According to a new report published by Jason Furman, chairman of the White House Council of Economic Advisers, over the last three years – the period since “Obamacare” became the law of the land – per capita health care spending has grown at a rate of 1.3%. “This is the lowest rate on record for any three-year period and less than one-third the long-term historical average stretching back to 1965,” Furman noted.

Moreover, thanks to health care reform, inflation for health care goods and services is “currently running at just 1 percent on a year-over-year basis, the lowest level since January 1962.”

How do we know the Affordable Care Act deserves credit, and this isn’t just a cyclical shift, or a reduction resulting from weak economic growth?
“The fact that the health cost slowdown has persisted so long even as the economy is recovering, the fact that it is reflected in health care prices – not just utilization or coverage, and the fact that it has also shown up in Medicare – which is more insulated from economic trends, all imply that the current slowdown is the result of more than just the recession and its aftermath,” the report stated. “Rather, the slowdown appears to reflect ‘structural’ changes in the United States health care system, a conclusion consistent with a substantial body of recent research.”

The ACA is a contributing factor because it includes reductions in Medicare overpayment to private insurers and medical providers, and incentives for hospitals and doctors to improve their quality of care, the report stated.

“Recent research implies that reforms to Medicare will have ‘spillover effects’ that reduce costs and improve quality system-wide,” the report stated. “Accounting for ‘spillovers’ implies that the ACA’s effect on health care price inflation may be much larger than previously understood.”
n terms of the real-world impact, this means more affordable care for consumers and more savings in government spending.

In other words, it’s the sort of thing Republicans should be pretty happy about – which generally means they’ll ignore the news and/or issue a press release declaring the opposite, assuming no one will know the difference.
posted by zombieflanders at 9:45 AM on December 9, 2013 [8 favorites]


So a better comparison would probably be between RomneyCare and ObamaCare since the Massachusetts plan was actually enacted and was endorsed by the Heritage Foundation.

TL-DR summary:

Similarities:
- State-based exchanges
- Subsidies for lower-income households
- The individual and business mandates

Differences:
- Size and scope
- Cost sharing for preventative services
- Medicaid expansion
posted by octothorpe at 9:45 AM on December 9, 2013 [2 favorites]


Given past experience of over-sized government agencies, I'm betting not. Certainly not to a country as far in debt as America is. But that's for another post, I suppose.

Indeed, the entire history of the federal government has just been a series of failures (i, ii, iii, iv, v, vi) and we should run its finances like a household.
posted by entropicamericana at 9:46 AM on December 9, 2013 [46 favorites]


It means a lot when the primary opponents of the law are opposed to the mandate specifically, which they themselves had no problem with when they proposed it.

Well yeah, obviously opponents of the mandate are hypocrites and loons, the sort of people who go around sitting on other people's pie because fucking up the seat of your pants is a small price to pay for ruining someone's dessert.

What I'm trying to say though, is that if we're trying to trace the DNA of the Affordable Care Act back to the Heritage plan, and all we can point to is a mandate, that doesn't really tell us much because pretty much any credible plan would have to include a mandate.
posted by Naberius at 9:48 AM on December 9, 2013 [2 favorites]


Certainly not to a country as far in debt as America is.

If only there were some other component to the Federal budget than spending...
posted by Gelatin at 9:49 AM on December 9, 2013 [29 favorites]


But the links did seem to show that a mandate was part of the Heritage Foundation plan.


Yes and that is the only similarity between the ACA and the Heritage plan.


Which went all the way to the Supreme Court to get approved, despite the fact that it was part of the original Heritage Foundation's and conservatism's plan.

If you want to argue other details of the plans are different, ok fine, but so what? The point is that one of the major components of the law turned into a huge fight for strictly political reasons. Which isn't surprising in politics, but it does point out the ridiculous hypocrisy as they argued against an idea they had originated.
posted by Brandon Blatcher at 9:53 AM on December 9, 2013 [2 favorites]


So, in the relevant context, the presence of a mandate in the ACA doesn’t establish any kind of fundamental similarity with the Heritage Plan. It just means that it’s universal health care reform designed by a non-moron.

Bias much? From what I hear Medicare is pretty successful and it doesn't have an individual mandate.

This guy does have some very valid points about the convenient conflation between the Heritage Plan and the Affordable Care Act, but his use of language ('lefties', 'unicorns', etc) demonstrates that he doesn't really have any intention of ever reaching out to or even listening to critics on the left and would rather insult them, Rahm Emanual style. That kind of marginalization of constituents is probably one of the reasons the whole 'Obamacare is just the Republican alternative from the 1990s' factoid got started in 2010.
posted by RonButNotStupid at 9:54 AM on December 9, 2013 [1 favorite]


I have to admit that I was spun as well, arguing that the ACA was basically the old Dole plan that was the GOP response to "Hillarycare." Seeing the real differences spelled out in black and white like that, I'm much more heartened that the ACA might actually have been worth it. Not that I wouldn't have preferred a Public Option or actual single-payer, but a step in the right direction is still a step in the right direction.
posted by ob1quixote at 9:57 AM on December 9, 2013 [1 favorite]


Why would the Heritage Foundation's seal of approval be a good thing?
posted by 1adam12 at 9:58 AM on December 9, 2013


Who the hell cares?

I assume that one reason Lemieux wrote his two pieces on this issue — here is the first one — was to refute the many liberals who deride the ACA as a "Republican plan", even though exactly zero Republicans actually voted for it.
posted by Eyebeams at 9:58 AM on December 9, 2013


Well, you can call me guilty of taking issue with the author without reading the whole article, because I couldn't make it past the half-assed logic of the second paragraph, where I think he's setting up his whole argument for why the ACA is not a Republican or Heritage Foundation idea.

First, he accepts that the individual mandate that is common to both the ACA & the Heritage plan is actually a common feature. Okay, fine. Then, he argues that that feature is insignificant because there was no alternative.

Which as an argument begs two questions: 1. was there really no alternative to including that component, and 2. would the lack of a practical alternative support the conclusion that the plans are different?

I don't buy the assumptions. Whether there were a practical alternative or not irrelevant. If my neighbor buys a truck, and I have to buy a truck for whatever practical reason, we both bought trucks. My lack of practical alternatives doesn't magically transform my GMC pickup into an Alfa Romeo.

Furthermore, the individual mandate is and was one of the main reasons leftists (speaking first-hand) were and are critical of the ACA. Not so much that people have to pay, but that we have to pay private insurers who function as toll booths on the road to health care but do not provide any useful service that the government could not provide more equitably and efficiently.

In fact, if you remember the 2008 primaries, Hillary's embrace of the Romney/Heritage plan was very unpopular with liberal/progressive Democrats, and Obama gave the impression that he would support a reform to the left of that.

Finally, we oppose the ACA/Heritage/Romney/Republican model not because it's got their brand name on it - I couldn't care less. If Heritage proposed a single-payer system, I would whole-heartedly embrace it as an acceptable compromise between the current private-profiteer system and a real, modern, universal national healthcare system.

So why is this complaint coming up now? Are centrist, pro-Obama Democrats uncomfortable with the realization that an essential feature of the ACA is the Heritage Foundation's brainchild?

Tough.

Suck it up and face the facts. Get your heads out of the clouds and come to reality, dreamers.
posted by univac at 9:58 AM on December 9, 2013 [6 favorites]


Then, he argues that that feature is insignificant because there was no alternative.

He also lists all of the ways in which the ACA is different from the Heritage plan. E.g. large expansion of Medicaid vs. block-granting of Medicaid. Preservation/incentivizing of employer-provided coverage vs. elimination of employer-provided coverage. Strong consumer protection requirements vs. no such requirements.

If you want to focus only on the mandate, fine, have fun, but I find Lemieux's argument completely persuasive.
posted by Eyebeams at 10:02 AM on December 9, 2013


Yes and that is the only similarity between the ACA and the Heritage plan.

It's the foundational element of each, that's like saying the "only" thing two brothers have in common is having the same parents.

The Medicaid expansion is a big deal, but it's really a separate idea that was aleo in the ACA. It wasn't Obama's main selling point or the Republicans main complaint. Not is it a logical necessity the way the mandate is for universal coverage and the abolition of pre-existing condition coverage denials.

The argument that "any" plan would include the mandate ignores tr fact that Democrats had at one point in the 90's actually had single payer as the goal, and that the mandate was a poig of debate in the 2008 Democratic primaries.
posted by spaltavian at 10:03 AM on December 9, 2013 [4 favorites]


1. was there really no alternative to including that component

There wasn't an alternative that wasn't actually socialist and evil so they probably don't count anything universal or single-payer-through taxes as being an alternative (even though both are technically mandating that everyone partake, its just the same mandate with every other tax: pay up or leave/go to jail).
posted by Slackermagee at 10:03 AM on December 9, 2013


The fact that Republicans complained a lot about the mandate makes it a "foundational" element? Really? I guess the contraceptive mandate must also be "foundational". And Obama made the mandate his "main selling point"? When was this?
posted by Eyebeams at 10:06 AM on December 9, 2013


Healthcare in the US isn't where it should be until no one fears losing their life savings from an illness, that everyone is able to have access to a good doctor, and prescriptions are available at a reasonable cost and not at a markup that reflects the cost of enforcing patents, billion dollar advertising budgets, and bilking the system for as much money as possible.

No one in Star Trek spends too much time looking for a bandaid. No one asks if their health plan covers a given condition... The captain is treated alongside the ensign and the stow-away... Medicine is done because it needs to be done, not because there's a better margin on it.

Is the ACA better than no ACA - yes... but it still isn't far enough. It doesn't matter where it came from - it matters that there's still work to be done.
posted by Nanukthedog at 10:06 AM on December 9, 2013 [2 favorites]


No discussion of universal health care is complete without acknowledging William Kristol's infamous 1993 memo from the effort to defeat "HillaryCare".

Yes, there's more to the ACA than the Heritage plan. The point is that the ASA is a (small-c) conservative plan, working with the existing insurance market to provide universal coverage instead of, say, even expanding an existing successful program like Medicare to cover everybody. And Republican opposition to it is both political and hypocritical in the extreme, even if the so-called "liberal media" lacks the institutional memory to figure it out.
posted by Gelatin at 10:06 AM on December 9, 2013 [2 favorites]


It's the foundational element of each

Another foundation element is that both plans will work with insurance companies to provide healthcare so people can be treated when their sick. So by that logic the Heritage plan is brothers with the NIH in Britain.
posted by MisantropicPainforest at 10:07 AM on December 9, 2013


Next the middle-of-the-road Dems are going to try to claim that Obama's wars are way different from Bush's, so learn to love them.
posted by univac at 10:07 AM on December 9, 2013 [1 favorite]


Oh come on.
posted by MisantropicPainforest at 10:08 AM on December 9, 2013 [1 favorite]


The NIH does not work with private insurers - the NIH is the "insurer." Fundamental difference.
posted by univac at 10:08 AM on December 9, 2013 [4 favorites]


The fact that Republicans complained a lot about the mandate makes it a "foundational" element? Really?

No, not really. That's not what I said.
posted by spaltavian at 10:08 AM on December 9, 2013


Obama's Orwellian surveillance is not anything like Republican Orwellian surveillance. In fact, it's really swell.
posted by univac at 10:09 AM on December 9, 2013 [1 favorite]


Then a fundamentall similarity is that they help people when they're sick. So they're fundamentally the same!
posted by MisantropicPainforest at 10:09 AM on December 9, 2013


Obamacare will help sick people. I will benefit from it because I am uninsurable in the private market and will be able to switch from COBRA.

But it came from the Heritage Foundation and shares essential features with Romneycare.

I support aspects of it. I oppose aspects of it.

Politics and policy are complicated.
posted by univac at 10:11 AM on December 9, 2013


Well simply repeating that the mandate is "foundational" while ignoring all the other elements of the ACA, including, weirdly, by calling them "separate ideas that were also in the [Act]" (??) isn't very persuasive.
posted by Eyebeams at 10:11 AM on December 9, 2013


> "In fact, if you remember the 2008 primaries, Hillary's embrace of the Romney/Heritage plan was very unpopular with liberal/progressive Democrats, and Obama gave the impression that he would support a reform to the left of that."

Wait, what? The second part of that isn't how I remember it at all.
posted by kyrademon at 10:14 AM on December 9, 2013


Given past experience of over-sized government agencies

What "over-sized government agency" was created by the ACA?
posted by yoink at 10:15 AM on December 9, 2013 [4 favorites]


"It seems to me like Lemieux is responding to criticisms of the ACA that just don't really exist in any vocal majority."

Apparently they DO exist, judging by the comments here and in the LGM threads.
posted by Eyebeams at 10:15 AM on December 9, 2013 [2 favorites]


Wait, what? The second part of that isn't how I remember it at all.

So far as I can tell, many progressive voters were the victims of a prank during the run up to the 2008 election in which every single time Obama spoke on their radios or TVs (and, presumably, every time his speeches were reported in their newspapers) the actual content was switched out for something unrecognizably different.
posted by yoink at 10:18 AM on December 9, 2013 [2 favorites]


kyrademon - I could be wrong about that. I remember he was critical. The rest is fuzzy.
posted by univac at 10:18 AM on December 9, 2013


But it came from the Heritage Foundation

Where is the evidence that it 'came from' Heritage?
posted by MisantropicPainforest at 10:20 AM on December 9, 2013


"But it [the ACA] came from the Heritage Foundation . . .

As Lemieux demonstrates, the individual mandate came from the Heritage Foundation. That's it.

. . . and shares essential features with Romneycare."

Correct. That would be the Massachusetts Health Care Act, passed in Mass. by large Democratic majorities in both houses and repeatedly vetoed by Gov. Romney.
posted by Eyebeams at 10:20 AM on December 9, 2013 [1 favorite]


I was turned on to this interesting feature of the Affordable Care Act, which I hadn't heard about: Medicare tax increases in 2013 for high income earners
As 2013 Begins, Get Ready For An Obamacare Tax Onslaught. So high-income earners, people making over $200k (single) or $250k (household) face up to 3.8% increase in their taxes, even on investment income.
posted by the man of twists and turns at 10:20 AM on December 9, 2013 [2 favorites]


So why is this complaint coming up now? Are centrist, pro-Obama Democrats uncomfortable with the realization that an essential feature of the ACA is the Heritage Foundation's brainchild?

This might have something to do with it:
Last Tuesday, the president and senior vice president of Third Way, a centrist think tank, published an op-ed in The Wall Street Journal lambasting Warren's plan to expand Social Security as "Exhibit A" of "populist political and economic fantasy.

....

Warren's call to expand Social Security — a proposal she laid out near the end of last month — is a stark contrast from the policy Democrats have embraced on the entitlement during the Obama administration. President Barack Obama included "chained CPI" — cutting benefits by changing the way cost-of-living adjustments are calculated — as a main concession to Republicans in his 2014 budget proposal.


posted by RonButNotStupid at 10:21 AM on December 9, 2013 [3 favorites]


It's the foundational element of each, that's like saying the "only" thing two brothers have in common is having the same parents.

Romney didn't want an individual mandate in "Romneycare." That was foisted on him by the Massachussetts legislature. And the Heritage foundation, while they generally approved of Romneycare, disliked the individual mandate portion of it.
posted by yoink at 10:21 AM on December 9, 2013


What "over-sized government agency" was created by the ACA?

My immediate thought was unrelated to healthcare: the DHS.
posted by Slackermagee at 10:21 AM on December 9, 2013


As someone else pointed out upthread, the ACA plan does however strongly resemble and share many features in common with the Republican endorsed plan Romney enacted with Heritage Institute endorsement in the state of Massachusetts.

So let's consider that angle for a second.

Is Romneycare a Republican supported and designed health care plan that seems to have provided a model for Obamacare? Well, yes, it is, isn't it? That's a true claim.

So even if the original Heritage Foundation health care proposal differed substantially from Obamacare on most points other than the mandate, that still doesn't necessarily obviate or otherwise belie the fact that Obamacare was ultimately based on a Republican-endorsed plan, as it very obviously did borrow heavily from the Republican-endorsed plan Romney enacted.

But this does seem like a particularly fussy and petty little side-road for the health care discussion in the US to go down. But then, it's politics all the way down, evidently, so by all means let's sort this urgent point of order out now for the good of the country before its too late!
posted by saulgoodman at 10:27 AM on December 9, 2013 [1 favorite]


As Lemieux demonstrates, the mandate came from the Heritage Foundation.

Not even that. To say it "came from" the Heritage Foundation is to suggest that it was some radically new idea that they dreamed up. Essentially any proposal designed to arrive at near-universal healthcare coverage in partnership with private insurance companies would have to include some version of a universal mandate--that or very draconian penalties for non-participation (e.g., "we won't treat you in our hospitals"--Romney's preferred solution).

I never really understand liberal opposition to the mandate because, of course, single payer systems are effectively identical on this point. In single payer systems we are all forced to pay for healthcare costs through our taxes. Some of us pay a lot more than others, of course, but that's exactly the same thing that happens under the ACA with the subsidies for poor people (and the tax increases on the wealthy). That's the nature of any humane healthcare system--you expand the risk pool as widely as possible, which means requiring shared payment from as wide a population as possible.

There are, of course, efficiency arguments to be had about single-payer vs. mandated participation in private insurance markets, but on the basic principle of whether or not we should all be required to "pay our share" the two systems are essentially indistinguishable.
posted by yoink at 10:28 AM on December 9, 2013 [5 favorites]


Is Romneycare a Republican supported and designed health care plan

No, it isn't. It's a health care plan that emerged out of bipartisan negotiations between a Republican governor and a Democrat-controlled legislature.
posted by yoink at 10:30 AM on December 9, 2013 [1 favorite]


Of course, some up-thread already seem to be laying the groundwork in this thread for claiming that Romney was forced to accept a liberal health care plan by the liberal legislature, but thankfully, we have video cameras now and it's not as easy for smarmy politician types to talk out of different mouths to different audiences without getting tripped up, as here's a video of Romney wholeheartedly endorsing and taking full credit for Romneycare (unless he was just lying).
posted by saulgoodman at 10:31 AM on December 9, 2013


But it came from the Heritage Foundation

Where is the evidence that it 'came from' Heritage?
posted by MisantropicPainforest at 10:20 AM on December 9 [+] [!]


Here you go.

They were for it before they were against it.

None of which "whose team did it" stuff is to say whether a policy is good or bad, but that the Republicans (and now a new gaggle of Dems apparently) are making wild justifications for their positions.
posted by univac at 10:31 AM on December 9, 2013


No, it isn't. It's a health care plan that emerged out of bipartisan negotiations between a Republican governor and a Democrat-controlled legislature.

Well, that's not what Romney has said, but I'm willing to call him a liar if you are.
posted by saulgoodman at 10:33 AM on December 9, 2013


yoink - the difference is that we support paying taxes for healthcare, but we don't want our money going to the for-profit insurers who are skimming off the system but provide zero healthcare.

Much the same way we're okay with tax dollars going to civil defense, etc but don't want it to end up in the hands of private corporations, Halliburton, et al.
posted by univac at 10:33 AM on December 9, 2013 [2 favorites]


Here you go.

They were for it before they were against it.


As your linked document shows, the only thing the Heritage Foundation proposal and the ACA had in common was the individual mandate. To say that the ACA is in any sense the "same plan" as the Heritage Foundation proposal is simply absurd.
posted by yoink at 10:36 AM on December 9, 2013


provide zero healthcare

Yes, that entirely imaginary situation would be a very bad one indeed. But perhaps it might be better if we restricted ourselves to actual, real world situations?
posted by yoink at 10:37 AM on December 9, 2013


saul goodman — My point was, the Mass. law was supported by the Dem controlled Mass. legislature as well as by the (minority) Republicans. And several features of the bill were vetoed by Romney - including the mandate. I apologize for any confusion.

"Here you go." Which is a link to the Heritage plan, which includes the mandate, and nothing else from the ACA.

On preview - What yoink said. But apparently no one is going to convince univac that the ACA is anything other than a Republican plan; the fact that not a single Republican voted for it being a weird historical accident I guess. That's fine.
posted by Eyebeams at 10:38 AM on December 9, 2013


Well, that's not what Romney has said, but I'm willing to call him a liar if you are.

Luckily, saulgoodman, we are not restricted to examining the speeches of Mitt Romney in order to reconstruct the history of the passage of health reform in Massachusetts.
posted by yoink at 10:39 AM on December 9, 2013


Also, that Heritage Plan univac linked is a vision-level planning document. It doesn't specify many details at all, just sketches out general approaches. The general approaches recommended are all perfectly in line with the approach taken in ACA. Specifically, the Heritage plan centers on three things:

1) Individual Mandate (check)
2) Financial help in form of tax credits for individuals without resources to buy a plan (check)
3) Greater control and regulation over the health care market itself (check)

Sure, the devil's always in the details, but there's not much room to debate from what I can see: The ACA is perfectly aligned with the parameters of the broader vision set out in the Heritage Foundation plan.
posted by saulgoodman at 10:39 AM on December 9, 2013 [2 favorites]


yoink - please explain what is imaginary. is your position that insurance companies treat patients?
posted by univac at 10:40 AM on December 9, 2013


Sure, but the only part Romney objected to was the part the Heritage Foundation endorsed!

"Here you go." Which is a link to the Heritage plan, which includes the mandate, and nothing else from the ACA.

Not true. All three of the big high-level features described in the Heritage plan are in the ACA!
posted by saulgoodman at 10:41 AM on December 9, 2013


Why is this ad-hominem debate happening over whether the ACA has Heritage's fingerprints or not? I think it's weird. It's not about policy substance.
posted by univac at 10:41 AM on December 9, 2013 [1 favorite]


The politics are pretty obvious, aren't they? A big part of Obama's push for bipartisan support for the plan was him touting its roots in conservative policy wonk circles, the point of which being to illustrate that Republicans in congress wouldn't even support their own side's policies if Obama proposed them. That tactic has worked pretty well, as the recognition that Republicans will oppose Obama and the Democrats over anything just to prevent them from succeeding is now accepted on a pretty widespread basis (based on my own informal studies of people I know).
posted by saulgoodman at 10:47 AM on December 9, 2013 [4 favorites]


Why is this ad-hominem debate happening over whether the ACA has Heritage's fingerprints or not? I think it's weird. It's not about policy substance.

That's not what's going on. It's the genetic fallacy, not the ad hominem fallacy.
posted by kewb at 10:50 AM on December 9, 2013 [2 favorites]


Some people seem to be drawing battle lines so that blame/credit for the ACA will be assigned correctly if it fails/succeeds. Another aspect is like saulgoodman says. If you're aware of the origins of the individual mandate came from conservatives it's not unreasonble to come to the conclusion many conservatives will oppose Obama and Democrats no matter what they propose. That they will change their ideology to suit their prejudices rather than the other way around.
posted by Green With You at 10:57 AM on December 9, 2013


My last comment:

2) Financial help in form of tax credits for individuals without resources to buy a plan (check)

Aren't the Heritage "tax credits" simply the elimination of FICA/Medicare taxes for eligible taxpayers? Which wouldn't finance shit in the way of health coverage? Haven't read the Heritage plan in a while but that's my recollection. The ACA provides for a true Federal subsidy.

3) Greater control and regulation over the health care market itself (check)

I don't remember this either; I thought the Heritage plan was to let The Market solve these kinds of issues. If I'm wrong, OK, though I doubt that (even taking into account that the Heritage document is a white paper, not a piece of legislation) it envisioned anywhere near the reforms that the ACA includes.

The ACA is inferior to single-payer and can be criticized on many bases. I think it's nuts to call it a "Republican plan" for the reasons Lemieux explains, but apparently YMMV.
posted by Eyebeams at 10:58 AM on December 9, 2013


So, in the relevant context, the presence of a mandate in the ACA doesn’t establish any kind of fundamental similarity with the Heritage Plan. It just means that it’s universal health care reform designed by a non-moron.

...and the ACA is basically what you get if you take the broader Heritage framework and use it to design a plan that's actually intended to provide coverage for people instead of being a fake idea that's only intended to be conservative talking points in response to more liberal plans from Democrats. The Heritage plan, only by non-morons.

Why is this ad-hominem debate happening over whether the ACA has Heritage's fingerprints or not?

Pointing out that it is at base a conservative plan -- and is specifically a conservative alternative to potential Democratic plans like Medicare expansion -- goes a ways towards showing what incoherent, nihilistic fuckheads the current crop of Republicans are.
posted by ROU_Xenophobe at 11:00 AM on December 9, 2013 [5 favorites]


Why is this ad-hominem debate happening over whether the ACA has Heritage's fingerprints or not? I think it's weird. It's not about policy substance.

A post was made, we argue about it. It's the cycle of strife.
posted by Brandon Blatcher at 11:01 AM on December 9, 2013


No, it isn't. It's a health care plan that emerged out of bipartisan negotiations between a Republican governor and a Democrat-controlled legislature.

it's important to note that Mass. is a one-party state that occasionally elects Republican governors when the various democratic party kingmakers can't decided on a candidate. so, the MA democratic party contains multitudes.

but more importantly, MA had a sizable single-payer constituency, and "RomneyCare" was definitely designed to sandbag them politically.

but, the important features of ACA isn't necessarily how it regulates it's insurance markets but how it preserves the differences between employer insurance, individual insurance, and charity insurance... insuring that the political blocs can be sliced and diced to avoid actually reforming the US health care system.

the single biggest failure of the single-payer crowd is this belief that paying for health care is the biggest problem our system has. in many ways, the US needs a British-style NHS to insure that non-specialist care is adequately funded and supplied. if you put everyone on medicare, you would discover that primary medical care is collapsing as a economically viable private enterprise.
posted by ennui.bz at 11:13 AM on December 9, 2013 [3 favorites]


The point of the piece is to shore up support for the ACA on the left, in order to undercut initatives such as Warren's, noted upthread.

Looking at my Facebook feed, I see numbers of marginal-income, middle-aged, partially-insured, formerly middle-class acquaintances complaining about how shocked they are at the cost of the still unaffordable and limited-coverage insurance they are being offered under the ACA, based on the newly functional website.

This is the core constituency for the ACA, and they are unlikely to see the cost of the insurance drop. The most popular choice at the moment seems to be to opt for the $95 penalty. These are people who have access to terrible high-deductible pay-as-you-go insurance via job or spouse, and therefore do not qualify for subsidies or tax credits (as they understand it).

The most common individual out-of-pocket cost for these sorts of ACA plans that I have seen quoted is around $8,0000 / year. One individual, also not eligible for subsidy or tax credit, estimated his household insurance base cost under the ACA to be $24,000/yr.

These numbers probaby actually do represent cost-plus averaged bases of individual health care costs across the society, I think, given that 20% of GDP is devoted to healthcare. But I would think that passing that cost downstream by mandating that marginal-income people spend 20% of household income on insurance might generate some resistance from the left.
posted by mwhybark at 11:14 AM on December 9, 2013 [6 favorites]


Well, that's not what Romney has said, but I'm willing to call him a liar if you are.

Pretty sure a veto has more evidential power than any statements.
posted by PMdixon at 11:15 AM on December 9, 2013


But I would think that passing that cost downstream by mandating that marginal-income people spend 20% of household income on insurance might generate some resistance from the left.

Probably a good thing that ACA is designed to limit expenditures to 9.x% of income then!
posted by PMdixon at 11:18 AM on December 9, 2013 [2 favorites]


Even if literally the only thing the two share is a mandate, then that's all they need to share, because a large chunk of what the conservative media has been shrieking about in terms of personal liberties, from the beginning, has been the mandate. While my state legislators have not been big fans of Medicaid expansion, it's not been the talking point that my boss has been going on about for the last two months. No, the thing he's been able to seize on out of all of this is how it's forcing people to buy insurance and how that's a violation of our personal freedoms and whatnot. Not that it's the only complaint out there, but it's a huge component, and it's the Republican contribution. We could have had a public option, you know?

I'll certainly agree that there are major differences, but the point isn't that they're exactly the same plan, it would be pretty shocking for any piece of legislation proposed to make it all the way through the process without some big changes. It's just that the Republicans did get to keep at least a chunk of what they wanted, and now they're claiming that none of this was their idea.
posted by Sequence at 11:18 AM on December 9, 2013


if you put everyone on medicare, you would discover that primary medical care is collapsing as a economically viable private enterprise.

... as the GDP share halved down to a western-democracy nominal 11.5%.

In order to make healthcare affordable, the current healthcare industry must undergo a catastrophic economic collapse. We may, therefore, expect them to spend a significant portion of the surplus GDP - oh, say 9% - to fight meaningful reform. Can any democracy resist that sort of political expenditure? It seems doubtful, to me.
posted by mwhybark at 11:18 AM on December 9, 2013 [1 favorite]


Probably a good thing that ACA is designed to limit expenditures to 9.x% of income then!

Well, that's just it: these folks are not subsidized, according to their accounts. The ACA is offering them what appears to be a 20% rate.
posted by mwhybark at 11:20 AM on December 9, 2013


Well, here's the high-level content from the Heritage plan itself ('...' indicates omitted content). Each of the major points in the plan also includes additional detailed proposals, of varying levels of abstraction, but at a high-level, all the basic elements of ACA are reflected in the proposal, by my reading:
Health System for America, the Heritage plan aims at achieving four related objectives:

+ + All citizens should be guaranteed universal access to affordable health care.
+ + The inflationary pressures in the health industry should be brought under control.
+ + Direct and indirect government assistance should be concentrated on those who need it most.
+ + A reformed system should encourage greater innovation in the delivery of health care.

...

The Heritage plan has several key components:

1) Change the tax treatment of health care.

...

2) Mandate all households to obtain adequate insurance.

...

3) Provide help to those who cannot afford protection.

...

4) Reform programs for the elderly.

...
posted by saulgoodman at 11:24 AM on December 9, 2013 [1 favorite]


1 and 4 mean eliminate employer tax deduction and Medicare. So no, not really the same.
posted by PMdixon at 11:29 AM on December 9, 2013 [1 favorite]


The Heritage Plan and the New Deal both reformed programs for the elderly so they are the same QED.
posted by MisantropicPainforest at 11:30 AM on December 9, 2013 [2 favorites]


Assuming that single-payer was never viable then yes I think there are some broad similarities between Obamacare and Romneycare. Enough at least that any compromise solution put forth by a Republican President would've largely resembled the basic structure of ACA.

Yes the ideal Republican ACA would look substantially different but as the Republicans are unlikely to get a filibuster proof majority in the Senate anytime soon, I think it makes sense that the compromise plan would still look very similar to ACA regardless of what party would present it.

I think everyone would admit that there have been problems with implementation especially because the Obama administration didn't realize how many states would forgo a state based exchange and how many states refused the medicaid expansion. But I think it's critical to note that the states experiencing the most pain from Obamacare seem to be those that refused Medicaid expansion and have decided to forgo state based exchanges. I think as there is more competition for these newly insured citizens there is also going to be continuing downward pressure on prices as healthcare providers seek to implement advances that reduce their net costs.
posted by vuron at 11:31 AM on December 9, 2013


The thing about a Repubican-supported ACA is it would be funded top-down and to hell and back, rather than be forced to be built piecemeal from whatever resources the individual agencies had to spare.
posted by Ardiril at 12:00 PM on December 9, 2013


This is how far to the right our politics has crept in America.

Obama is considered liberal and so-called liberals are promoting ideas that 25 years ago were Republican.

And Canadian-Style single-payer isn't even on the table, even thats what he majority of Americans would want if asked an honest question.
posted by Pirate-Bartender-Zombie-Monkey at 12:02 PM on December 9, 2013 [3 favorites]


What ideas were Republican but are now promoted by liberals?
posted by MisantropicPainforest at 12:06 PM on December 9, 2013


President McCain would have passed no health care bill. Describing a Republican ACA is silly because there wouldn't have been one.
posted by PMdixon at 12:10 PM on December 9, 2013


And so the rewrite of history begins...
posted by Mental Wimp at 12:14 PM on December 9, 2013


PMdixon: Yup.
posted by Ardiril at 12:25 PM on December 9, 2013


I guess I don't see how you get universal coverage without either single payer or an individual mandate. No one else seems to either.

Joe Lieberman was not going to vote for single payer.
posted by PMdixon at 12:26 PM on December 9, 2013


What ideas were Republican but are now promoted by liberals?

Neoliberalism and Market-based healthcare over single-payer leap to the top of the list. Imagine a republican today advocating Nixon's proposed national healthcare plan.

Republican politics have been demonstrably shifting towards the right for decades, and the Democrats (in an insipid attempt to seem "centrist") creep rightwards to follow them.
posted by Pirate-Bartender-Zombie-Monkey at 12:28 PM on December 9, 2013 [8 favorites]


President McCain would have passed no health care bill. Describing a Republican ACA is silly because there wouldn't have been one.

I think Ardiril was suggesting an ACA bill lead by Obama but with some significant Republican support from congress. If ACA had more bipartisan support, like Medicare, Civil Rights, Social Security, etc, it makes sense that it could have been implemented better, and hopefully as time went on it would have moderates from both parties helping to make it succeed. The fact that ACA was apparently passed without any Republican votes is not ideal, especially if Republicans continue to do everything possible to insure its failure.

Considering the similarities between RomneyCare and ACA and that Obama did his best to include Republicans in the process of forming the bill, it doesn't seem like there were very good reasons for Republicans to refuse to compromise and take some ownership of the bill. I'm not sure both parties are moving to the right, but I think we are definitely seeing less cooperation and more outright confrontation between the parties, and I don't see how this could be good.

Honestly, considering what a disaster Healthcare.gov has been, I'm not confident that a single payer system supported by only Democrats would have been the best outcome. If ACA as it is fails miserably, I don't think it will be good for liberalism.
posted by Golden Eternity at 12:29 PM on December 9, 2013


Bias much? From what I hear Medicare is pretty successful and it doesn't have an individual mandate.

It kind of does. Note that the cost of health care insurance as you age beyond 65 becomes prohibitively expensive if not subsidized and you are penalized by stiffly increasing premiums for delaying signing up for Medicare (I think somewhere around 10% a year). Note that the ACA "mandate" is really just a tax exemption in reverse, as SCOTUS cited. Given that you eventually will need Medicare as you age (if you are not fabulously wealthy), then there is kind of a mandate to register for Medicare at age 65.
posted by Mental Wimp at 12:30 PM on December 9, 2013


eoliberalism and Market-based healthcare over single-payer leap to the top of the list.

So, the Clinton health care plan.
posted by MisantropicPainforest at 12:31 PM on December 9, 2013


From what I hear Medicare is pretty successful - Obviously you don't have to deal with it. A former cardiologist is still trying to get paid for an implanted defibrillator from 3 1/2 years ago because someone at CMS transposed a payment code.
posted by Ardiril at 12:34 PM on December 9, 2013


Threadsitting much, MP?
posted by Pirate-Bartender-Zombie-Monkey at 12:34 PM on December 9, 2013 [2 favorites]


The real reason for the GOP's all-out war on Obamacare
At its core, the Republicans' scorched-earth opposition to Obamacare has never been so much about "freedom" or "limited government" or any other right-wing ideological buzzword as it has been about political power, pure and simple. Now as for the past 20 years, Republicans have feared not that health care reform would fail the American people, but that it would succeed. Along with Social Security and Medicare, successful health care reform would provide the third and final pillar of Americans' social safety net, all brought you by the Democratic Party. To put it another way, the GOP was never really concerned about a "government takeover of health care", "rationing", "the doctor-patient relationship" or mythical "death panels," but that an American public grateful for access to health care could provide Democrats with an enduring majority for years to come.
posted by Pirate-Bartender-Zombie-Monkey at 12:37 PM on December 9, 2013 [7 favorites]


Honestly, considering what a disaster Healthcare.gov has been, I'm not confident that a single payer system supported by only Democrats would have been the best outcome.

But ACA required constructing a new system. For single payer, simply expand Medicare and Medicaid to everyone. Fini!
posted by Mental Wimp at 12:37 PM on December 9, 2013 [2 favorites]


I think the disconnect, MisantropicPainforest, is this: the left saw the mandate as mandating participation in what was once a predatory market. This was the right's idea originally, the mandate.

This then skews the entirety of the bill to the right, making it the conservative thing, as it doesn't divorce US healthcare from a predatory market and only binds everyone to it tighter. It also makes it less abusive, more customer serving, and more efficient in the process but its still 'the bad guys' who we're all being pushed into the arms of.

At which point Vermont collectively threw up its hands and said, "Fuck it, we're out. Come here if you want to escape the market."
posted by Slackermagee at 12:39 PM on December 9, 2013 [2 favorites]


Now as for the past 20 years, Republicans have feared not that health care reform would fail the American people, but that it would succeed. Along with Social Security and Medicare, successful health care reform would provide the third and final pillar of Americans' social safety net, all brought you by the Democratic Party.

That's pretty much the point (though couched in "Democrats-are-buying-votes-with-taxpayer-funded-goodies" language) of the Kristol memo I mentioned earlier.

(That memo is notable for being perhaps the only time Bill Kristol has been right about anything.)
posted by Gelatin at 12:41 PM on December 9, 2013 [1 favorite]


Honestly, considering what a disaster Healthcare.gov has been, I'm not confident that a single payer system supported by only Democrats would have been the best outcome.

Bipartisan support wouldn't have done much to fix Healthcare.gov, though. The states opting out of the Medicare expansion wouldn't be as much of a problem, sure, but the website still would've been put together by similar contractors. But likely a bipartisan version of the ACA would be even more hobbled by compromise, and I don't really want to have a system like that. The picture of that I've got in my head is the Medicare expansion not even being on the table, an even sweeter deal for the insurance companies, some looting of social programs to pay for it all instead of taxes, birth control being cut out entirely... I don't want bipartisanship with the current Republican crowd on something like healthcare.
posted by jason_steakums at 12:44 PM on December 9, 2013


The issue is not whether ACA and Romneycare and/or the Heritage plan are fundamentally similar or different. That's a philosophical question and anyone with a strong feelings one way or the other is unlikely to be swayed. More fundamentally, the practical issue -- which Lemieux is fairly explicit about -- is whether the center-left will allow the far-left to compare ACA to those conservative plans in making their criticisms of ACA from the left. Lemieux doesn't really help his case, in my mind, because he bases it on arguments that regard all elements of the plans as equally important; uses ad hominem and extreme language ("absurd" "nyuk nyuk nyuk", etc); regards pragmatics as defining similarity (single payer wasn't possible, so ACA must only be contrasted with other similar plans, not single payer); and ends with a somewhat confusing thought-experiment. But the article is clearly not aimed at convincing the far left. Rather, it is aimed at providing more arguments for the center-left, to make sure they are un"spun" by the radical left.

If we step back from the article, the basic issue remains: should the far left stop complaining, abetting the bad press for Obama, or not? This is just another skirmish in that larger war about how to manage the publicity issues due to the website and, more importantly, due to the growing numbers who are dissatisfied with the changes to their healthcare. The left as a whole generally agrees that the main problems are mostly due to the conservative elements of ACA (eg, the complex interactions between mandates, markets, free-riding, etc). The question is what to do about it: Stop comparing it to the Heritage foundation and support it as a genuine improvement of the status quo, the best plausible accomplishment at the time, and the best shot for Democrats in the upcoming elections? Or critique its regressive, market-based structure as yet another step rightward for the Democrats and the cause of most of the individual-level unhappiness with the plan's effects? Lemieux's article is mainly another push in favor of the former and against the latter.
posted by chortly at 12:45 PM on December 9, 2013 [2 favorites]


One individual, also not eligible for subsidy or tax credit, estimated his household insurance base cost under the ACA to be $24,000/yr.

Man, it must really suck to make... /does a little math using the 9ish% stipulated by the ACA... OVER TWO HUNDRED FUCKING THOUSAND DOLLARS A YEAR.

Fucking Persian rugs cost so much to clean, and you can't even wear your shoes on them. What's worse, now I'm hearing that my custom Algerian Granite countertops may be leaking radiation. OHNOES.

This is why there was a thing called the French Revolution. These people are aware that this number puts them squarely into the 1% category, right?
posted by Blue_Villain at 12:46 PM on December 9, 2013 [1 favorite]


At which point Vermont collectively threw up its hands and said, "Fuck it, we're out. Come here if you want to escape the market."

Right, Vermont was able to do this because the "Republican" ACA allows states to establish public plans.
posted by Eyebeams at 12:49 PM on December 9, 2013


Blue_Villain — The 9.5% cap does not apply to all income levels. You can make a lot less than $200,000 and get no premium subsidies.
posted by Eyebeams at 12:50 PM on December 9, 2013


These people are aware that this number puts them squarely into the 1% category, right?

Let me say from familial experience that, no they don't always realize. They certainly associate with the value of wealth and having some portion of your offspring running around spouting off on the unfair/destructive division of resources and the downfall of the scarcity economy one's salary is based off of tends to generate some friction and occasionally dissonance.

Right, Vermont was able to do this because the "Republican" ACA allows states to establish public plans.

I'm confused by the quotation marks and that being a states rights thing.
posted by Slackermagee at 12:51 PM on December 9, 2013


I doubt that any Republican would vote for a public option — whether federal or State. And in the event, they didn't.
posted by Eyebeams at 12:55 PM on December 9, 2013


But surely Republicans would agree that a State has a right to choose for itself whether or not it wants a State provided public option?
posted by Golden Eternity at 12:57 PM on December 9, 2013


States Rights is only for important things like racism.
posted by Artw at 1:01 PM on December 9, 2013 [11 favorites]


What ideas were Republican but are now promoted by liberals?

Well, there's emancipation.

Republican politics have been demonstrably shifting towards the right for decades, and the Democrats (in an insipid attempt to seem "centrist") creep rightwards to follow them.

Democratic nominate scores (what that article is talking about) have shifted slightly to the left, not to the right. Republicans have been voting in every more intensely conservative patterns, but the Democrats haven't been following them; they've stayed put or taken a baby step to the left. But nominate scores only look at patterns of agreement and disagreement among MCs; any interpretation of the dimensions that fall out is done by analysts (like Poole, Rosenthal, or McCarty. Or me.) after the fact.
posted by ROU_Xenophobe at 1:06 PM on December 9, 2013 [2 favorites]


I thought it was repackaged Romneycare? And this whole tirade by Republicans was just, we never nominated Romney, no we didn't, la-la-la. Chief Justice Roberts didn't declare it constitutional, no he didn't.

It is repackaged Romneycare, which is the crown jewel of Romney's legacy as governor of Massachusetts in a lot of people's eyes...Including Romney's, I would guess, going by the way he just could not bring himself to renounce it even during the Romney/Obama election when it cost him the ability to attack Obamacare with any legitimacy.

If Massachusetts weren't such a liberal state, Romneycare probably wouldn't have been passed or even proposed -- it wasn't some labor of love on Romney's part, I'm sure. But Massachusetts *is* a liberal state, Romneycare *did* get passed, it *is* generally considered to be a success and remains popular -- to the point that, even with the presidency at stake, Romney couldn't bring himself to shy away from credit for it.

12 years from now if ACA is a success the Republicans will be claiming it was all their idea.

They'll have to, if they want to keep any grasp of power outside of the Tea Party and/or libertarians. They went after Clintoncare so rabidly because they knew that if they let Clinton provide everyone with health care that they'd lose basically an entire generation to the Dems.

They're going to block any attempt by Obama and/or the Dems to provide people with things people will be very grateful to receive, like health care, jobs (a la CCC or CWA programs), food, etc, because the recipients of those programs are likely to be loyal for life -- it'll be FDR and a decades-long Democratic House all over again.

But barring their ability to block the reforms, they will at least try and take credit for them once the reforms are already popular.

...in other words, basically what Gelatin was talking about w/r/t the Kristol Memo and what Pirate-Bartender-Zombie-Monkey was talking about w/r/t the quote from the Perr article.

Blue_Villain — The 9.5% cap does not apply to all income levels. You can make a lot less than $200,000 and get no premium subsidies.

There are some major holes in the subsidies -- actually, one that bothers me even more than people having to take their employer's plan (or spouse's employer's plan) if offered and not buy directly from the exchange, is the hole for people under the poverty line in states that have refused to expand Medicaid. If you earn <100% of poverty in a state that has refused Medicaid expansion, you're basically SOL in terms of getting any insurance -- you're going to have to pay the $95 opt-out fee and rely on community walk-in clinics (who can't even do basic things like refer you to specialists).

The reason I have less trouble with the people who are forced to take employer-offered plans is that at least the plans themselves are now forced to provide a minimum of security. They're not as terrible as pre-ACA, so even people taking relatively shitty, relatively expensive plans are receiving some protections they weren't before (no lifetime caps, limited out-of-pocket expenses, etc). And Obama is taking very seriously his "you can keep your insurance" and "you can keep your doctor" statements and has been cracking the whip with HHS to make sure those things are actually happening, so he's attempting to make sure that individual people will face the absolute minimum of disruption based on the ACA.

But those are ways in which the ACA is failing because it isn't *liberal enough.* If we're going to go down the "ways I would make the ACA more liberal" road, then why stop at how to change the subsidies, or having the Medicaid expansion be on the Federal level instead of trying to tempt states into accepting it themselves by offering them free money for the expansion? At that point, personally, I'd prefer single payer. And yeah, they do know how to implement single-payer and there are plenty of politicians who'd love to take credit for getting good, cheap health care to all their constituents, but because of the zero-sum party polarization that's been going on, that's just not something that's going to pass. This is as liberal a health care act that was going to get passed, and niggling over the ways in which it's not *quite* liberal enough is losing the forest for the trees, in my opinion.

Personally, the ACA reforms have very positively affected my own care. Even aside from the reforms that are already operational, starting Jan. 1, I'll be receiving much better insurance protections and a lot more of the preventative/wellness care that I need, and at the cost of $7/mo. The ACA is going to help a *whole* lot more people than it's going to hurt, and while I wish it helped even more people and helped them more than it currently does, I'm happy that at least we've got this much.

Also, if you're having issues with the exchange and insurance affordability, seriously -- write an email or letter to Obama about it. The ACA is honest-to-god his baby, he's trying hard to make it work. This weekend, he had HHS employees *who literally wrote the policy* call thousands of ordinary people who had written to him with issues regarding how they're affected by the ACA. The point was so that the HHS employes could look into fixing policy holes and/or to walk the ordinary people through troubleshooting.
posted by rue72 at 1:33 PM on December 9, 2013 [7 favorites]




Anyone who used the "ACA = Heritage proposal" argument who wasn't aware they were speaking loosely is an idiot. Of course the ideas taken in their whole parts are different. But the aorta of the ACA is the mandate, and you can find the Heritage paper regarding that idea on the internets.
posted by NedKoppel at 4:41 PM on December 9, 2013


So Obamacare shares the basic premise, then adds in protections, or in other words eliminates or partially eliminates the worst aspects of the Heritage Foundation plan. Those are points to quibble and debate, for sure, but any responsible polling would reflect that the vast majority of Americans would favor the changes. Obama ran on that plan and even got re-elected based on it.

Republicans still want to repeal it? By the time they'll get a chance to, maybe as early as next year-ish, there will be that many more people--red state, blue state, whatever--who will have enrolled in a plan and that many more people the Republicans will have to say "Look, I know you're enjoying your new healthcare that you've never had before, but vote for me and we'll go back to the way it was before." It'll never happen. And if it does on the downlow somehow, by some really sleazy backhanded fashion that would not surprise me in the least, it would just hurt Republicans all the more.

More work needs to be done, and hopefully in my lifetime we'll switch to single payer. But the transition has happened. Ain't no going back now.
posted by zardoz at 5:15 PM on December 9, 2013 [3 favorites]


Bronze plan (no subsidies available): Pay a $3000 premium with a $6000 deductible and the IRS refunds anything out of pocket over 9.1% next time taxes roll around.

-or-

Pay a $96 tax and wait until 2015 to see how things shake out.

(prices approximated)
posted by Ardiril at 6:49 PM on December 9, 2013


I think the plan also includes a special feature that allows the tax credit to be applied at the time of purchasing insurance on the market. Basically, qualifying people can get the benefit of the subsidy upfront, rather than having to wait to be reimbursed at year-end tax time. Not sure what the qualifying conditions are. The tax credit is set to expire 2014, so if it does any good, you can be sure there'll be a big fight over extending it in congress.
posted by saulgoodman at 9:25 PM on December 9, 2013


And Canadian-Style single-payer isn't even on the table, even thats what he majority of Americans would want if asked an honest question.

Is that true? It's all anecdotal for me but even the left-wing Americans I know have given me the old "unacceptable wait times! Second-rate care!" speech.

And to be honest when I developed a food allergy recently it took over a year to see an allergist, but otherwise my experience here has been good. Seeing the allergist was the exception. I guess the theory is that in the span of a year, you'll probably figure out what it was you were allergic to through a process of elimination.
posted by Hoopo at 10:41 PM on December 9, 2013


Either by eliminating the food or by eliminating yourself, yes.
posted by Justinian at 10:41 PM on December 9, 2013 [1 favorite]


I think the plan also includes a special feature that allows the tax credit to be applied at the time of purchasing insurance on the market. Basically, qualifying people can get the benefit of the subsidy upfront, rather than having to wait to be reimbursed at year-end tax time.

If you're on the federal exchange, you have to answer the question of whether you want all of the subsidy applied to your monthly premium, if you want some of it applied and some of it held back as a credit on your 2014 tax return, or all of it held back as a credit on your 2014 tax return.

That's probably (though I don't know for sure) actually a legal issue, because the subsidy is *your* money, but if you choose to apply it to your monthly premiums, it'll be sent directly from the government to the insurer (and the remainder of your monthly insurance premium will be invoiced to you by the insurer on a monthly bill). The government can't just send your money to the insurer, it has to ask you if that's OK with you first.

If you're interested, here's a walk-through of going on the federal exchange*, based on my experience (and the zillions of questions I ask everybody, panels I've gone to, etc -- that's mostly for fun, though, because I'm fascinated by this stuff):

1. Fill out the eligibility form. You get asked (very basic) questions like your name, if you're married, etc. Nothing that you'd have to look up. Takes approximately 2 minutes.

2. Estimate your 2014 income. You can go through a kind of calculator, or you can tell the computer to use the income amount from your 2012 tax records (in which case you don't have to answer any more questions in that section). If you overestimate your income (but your actual income doesn't fall below 100% poverty), then you'll get money back on your 2014 tax refund, and if you underestimate your income, you have to pay some of that money back (the amount of "extra" subsidy you received) as part of your 2014 tax bill. The calculation of income that the government is using is also not gross income, it's a version of adjusted income. Takes approximately 5 minutes.

3. Receive a pdf outlining your eligibility. The pdf pretty much just tells you the dollar amount of your subsidy (though there's also some explanations of what the subsidy is, what the ACA entitles you to, etc). If your income is >400% of the poverty level, I don't think you get a subsidy, but, per usual, you do still get tax write offs for health/medical payments over 10% of your income if you itemize your taxes (though that's up from I think 7.5% of income previously). Once your income estimate goes through, you receive the pdf instantaneously.

4. Indicate how you want your subsidy applied. Do you want all/some/none of your subsidy applied to your monthly premiums (as opposed to none/some/all of your subsidy to your tax refund).

5. Answer 2-3 basic health/lifestyle questions. The questions are things like, "do you smoke more than 4 cigarettes a week," not anything about your medical history or anything. Again, nothing that you'd have to look up. Takes about a minute.

6. Go onto the exchange. As of when I went on the exchange last week or so, the premium amounts that they have listed *are now the post-subsidy premiums.* So for example, I'd answered that I wanted to use all of my subsidy toward my monthly premiums, so that meant that I got $222 applied to my premium each month. A good "silver" plan (no deductible, etc) from the insurer I wanted was approximately $230/mo -- it came up as $7.83/mo on the exchange, with the subsidy already subtracted (though I think that there was a place where I could see the original price? I think I had to go to the detail section to see it, though). Also, you can compare plans side-by-side. It's pretty simple and self explanatory -- actually, it's very similar to shopping for a cell phone on your phone company's site or something. Takes about fifteen or twenty minutes, depending on how easily you narrow down plans.

7. Click "enroll" on your chosen plan. You're enrolled! If you enroll before Dec. 23, your insurance will start on Jan. 1, but it's open enrollment through March 31 (you're not liable for the opt-out fee if you enroll before March 31 -- I'm not sure about what happens if you enroll between April and the end of 2014). You're going to get a monthly invoice for the amount that came up as your post-subsidy premium, starting this month (for January). The actual insurance is just regular insurance, like you're used to having from any group or individual plan.

*If your state has an exchange of its own, I *think* (though I'm not sure) that you're supposed to use your state's exchange. My state doesn't have an exchange, so my knowledge of how state exchanges work or connect with the federal exchange is pretty hazy.

If you're at all curious or wonder if you might be eligible for something, I really encourage you to go on and at least fill out the eligibility questions and get your pdf outlining your eligibility. The questions aren't invasive, it's not a time suck, and you can delete your eligibility form/questions at any time (and start a new one, if you want to change your income estimate or who will be on the policy or something).

Also, if you've been on before and found it confusing or annoying, you might want to try again. I had some issues the first time I tried to shop for plans/enroll, but since then, they've apparently done a ton of troubleshooting and it ran very smoothly for me this time around.
posted by rue72 at 10:59 PM on December 9, 2013 [3 favorites]


Lemieux has posted a follow-up to the article linked above.
posted by burden at 6:38 AM on December 10, 2013


The tax credit is set to expire 2014, so if it does any good, you can be sure there'll be a big fight over extending it in congress.

The tax credit is a permanent part of the ACA. It does not expire. It is an essential part of the ACA because if you have an insurance mandate you must have a way for low-income people to pay for it.

Here is the ACA in a nutshell:

1. No restrictions on health status or pre-existing conditions, which implies
2. Insurance mandate to prevent gaming the system, which implies
3. Subsidies for those unable to afford insurance.

That's the whole ACA (plus a lot of other details).
posted by JackFlash at 8:48 AM on December 10, 2013 [2 favorites]


I'm really glad Lemieux is doing these posts. There has been some rhetorical advantage gained by describing it as a Republican plan, but the GOP's opposition isn't going to change just because it happens to share one key feature with a plan that a right-leaning think tank proposed 20 years ago, but that would clearly not have gotten enough GOP votes to pass either then or now.

This isn't the plan I wanted, so I sought some refuge in the "Republican plan" label, but there is enough good in it that we need to start taking ownership of it and recognizing that it's far to the left of what the GOP disingenuously proposed back then, and even farther to the left of what the GOP would propose now, or what they would allow to pass now.
posted by tonycpsu at 9:06 AM on December 10, 2013 [1 favorite]


Hey, remember when Libertarian uber-magazine Reason was all about an individual mandate in 2004?

All the ACA media drama was focused on the mandate...with republicans crying about how unconstitutional it was, when it was - in fact - supported in years past by their peers. The fact that the actual Heritage plan differed insofar as it punished the sick and the poor far more than the actual ACA is unsurprising and irrelevant.

The ACA drama revolved around the mandate. The mandate was lauded by neo-liberals before it was booed. That point still has legs and underlies the degree to which these self described patriots cherry pick from the constitution when it suits them.
posted by jnnla at 11:14 AM on December 10, 2013


The existence of political drama doesn't make an argument. Striking the mandate would significantly increase the cost of the ACA, which would doom it politically, but wouldn't change the provisions that actually matter to beneficiaries.
posted by tonycpsu at 12:30 PM on December 10, 2013


Uh, striking the mandate while leaving intact guaranteed issue and community rating would completely destroy the insurance industry. Not in the clean quick way single payer would, in the death spiral way.
posted by PMdixon at 1:49 PM on December 10, 2013 [1 favorite]


PMdixon: "Uh, striking the mandate while leaving intact guaranteed issue and community rating would completely destroy the insurance industry. Not in the clean quick way single payer would, in the death spiral way."

The ACA as it exists today already has provisions for protecting insurers against losses if not enough "young invincibles" sign up. Nuking the mandate would increase these losses significantly, which, as I said, would just increase the cost of the bill. It would do so quite dramatically, which is why I said it would doom it politically, but the mandate has nothing to do with the coverage offered, only with how much it costs to cover the people who choose not to buy it.
posted by tonycpsu at 1:54 PM on December 10, 2013 [1 favorite]


The ACA as it exists today already has provisions for protecting insurers against losses if not enough "young invincibles" sign up. Nuking the mandate would increase these losses significantly, which, as I said, would just increase the cost of the bill.

The reinsurance provisions are temporary, only for the first three years. This is prevent any surprises on the balance between premiums charged and benefits, depending on how many and what kind of people sign up. After the three years, insurers are expected to have enough experience in this new market to accurately set their rates without reinsurance protection. The reinsurance program will end and insurers will be responsible for their own losses.

The lack of a mandate would cause a revenue shortage but in the long run is would also cause an adverse selection death spiral. Not all medical conditions are emergencies -- for example hip replacement, knee surgery, diabetes, arthritis. Many people would choose to sign up only if they developed an expensive condition with guaranteed issue. And they might cancel as soon as their expensive treatment was finished. This would cause premiums to rise which would encourage even more people to drop out of insurance until they got sick.
posted by JackFlash at 3:19 PM on December 10, 2013 [1 favorite]


It's only a death spiral if the feds stop pumping money in -- otherwise, the premiums can stay the same and the feds can cover the losses that come from people not using insurance until they need it. At some point, they become less insurance companies and more tightly-regulated public utilities that provide insurance servicing on behalf of the federal government, but the point is that it's really a feature of making the cost numbers balance out.
posted by tonycpsu at 4:33 PM on December 10, 2013 [1 favorite]


Uh. Yes I do think back door nationalization of the insurance industry (which appears to be what you're suggesting could happen in some theoretical world where the mandate is struck and the reinsurance provisions extended indefinitely?) would be a political nonstarter.

Good thing no one is suggesting that.
posted by PMdixon at 4:43 PM on December 10, 2013


PMdixon: " Good thing no one is suggesting that."

I didn't say anyone was. My statement was that, cf. Lemieux's chart showing that the only thing the ACA has in common with the original Heritage plan (only nominally supported by Republicans so they could say they had a plan, not actually something they'd have cast a meaningful vote for) is the mandate, and that the mandate doesn't have fuck all to do with anything relating to actually covering people. There's way more to it than the mandate, so focusing on the one similarity with the Heritage plan to say the ACA is "a Republican" plan is neither accurate nor productive for people who want to make the law more progressive.
posted by tonycpsu at 4:55 PM on December 10, 2013


More from Scott Lemieux, this time on suggestions that, instead of the ACA, Obama should have pursued Medicare/Medicaid expansion.
posted by tonycpsu at 11:27 AM on December 12, 2013


Conservative health-care-policy ideas reside in an uncertain state of quasi-existence. You can describe the policies in the abstract, sometimes even in detail, but any attempt to reproduce them in physical form will cause such proposals to disappear instantly. It’s not so much an issue of “hypocrisy,” as Klein frames it, as a deeper metaphysical question of whether conservative health-care policies actually exist.

The question should be posed to better-trained philosophical minds than my own. I would posit that conservative health-care policies do not exist in any real form. Call it the “Heritage Uncertainty Principle.”
The Heritage Uncertainty Principle
posted by Pirate-Bartender-Zombie-Monkey at 10:59 AM on December 14, 2013 [2 favorites]


A Health Care Mystery Explained
And here’s the thing: Republicans don’t want to help the unfortunate. They’ll propound health-care ideas that will, they claim, help those with preexisting conditions and so on — but those aren’t really proposals, they’re diversionary tactics designed to stall real health reform. Chait finds Newt Gingrich more or less explicitly admitting this.
posted by the man of twists and turns at 11:47 PM on December 15, 2013 [3 favorites]




Oh New York Times, promise me that you'll always keep me informed on the plight of people with higher incomes than 85% of the rest of the country. Lord knows it's tough out there for those making low six figures.
posted by octothorpe at 4:05 PM on December 21, 2013 [6 favorites]


Michael Moore decided to employ the "ACA is a GOP plan" rhetoric in his recent NYT op-ed. Lemieux responds.
posted by tonycpsu at 11:13 AM on January 3, 2014


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