• On the obligation to oppose

    This is a joint post by Austin Frakt and Aaron Carroll.

    Ross Douthat has a measured and reasoned response to our support for a discussion about Medicaid reform simultaneous with encouragement of expansion. Stop now and go read it. Then come back.

    Douthat makes some excellent points, with which we largely agree, and one point with which we do not.

    America rarely just “tries out” major expansions of the welfare state: Rather, our history strongly suggests that programs in motion tend to stay in motion, and that the best time to change a potentially-dysfunctional system is before it gets entrenched — before interest groups organize themselves around perpetuating those dysfunctions, before voters become accustomed to the program’s guarantees, and before the political system learns to take its existence for granted and turns to other debates instead. Whereas once something becomes the Way We Redistribute, it’s both hard to pare back and harder to propose alternatives, no matter what the data ultimately show about the program’s actual effectiveness.

    It’s true, as Frakt and Carroll note, that no alternative reform is likely to be implemented as quickly as Obamacare itself. But it’s also true that if you favor a substantially-different alternative, cheering on the law’s full implementation while participating in a “conversation about how to make [it] more efficient and effective” is likely to lead to that alternative being passed sometime around the Fourth of Never. And this reality means, in turn, that for all the dilemmas that the current state of the Republican Party creates for thoughtful opponents of the new health care law, they still have an obligation to oppose.

    The “obligation to oppose” is an illogical leap from a premise with which we agree. It is true that it will be hard to change a redistributive program once it begins doing its redistributing. Path dependency is a real thing. The state of our health system and the difficulty in changing it demonstrates it.

    But recognizing that does not by itself obligate anyone to oppose Medicaid expansion. It only suggests one should weigh its likely inertia and imperfections against the moral implications of doing nothing. We, ourselves, have confronted this dilemma. There are many things we’d like to change about Medicaid and other facets of our health system. We understand that it will be hard, and some things we dislike may never change. Yet we are not obligated to oppose any more than we’re required to support. One has to do the moral calculus for oneself. One can still come down on the side that doing nothing is preferable to expanding Medicaid in one of the forms currently permitted by law. But, by no means is one obligated to do so.

    To suggest obligation is a direct appeal to political loyalty, is it not? If this is about politics then we will concede the point to Douthat and move on. But if we’re talking how to craft policy to help poor Americans, that’s a discussion in which we want to participate, but only if we shed this nonsensical idea that anyone is obligated to anything. Is this an open minded discussion or not?

    We want to re-emphasize the context of this discussion. Medicaid expansion, and the ACA in general, isn’t arbitrary policy. It had the support of the a majority of the House of Representatives, a supermajority in the Senate, and the President of the United States, who ran with health reform as a major plank of his platform. And then he won re-election. The policy was even examined and modified by the Supreme Court, on which sit a majority of conservative-appointed Justices.

    Moreover, it’s not like there isn’t room for movement within the law. Do you want more of a managed care option? That’s what Florida’s governor got. Do you want more private insurance options instead? That’s where Arkansas is headed. The Obama administration seems more than willing to negotiate. That some alternative to traditional Medicaid will be possible on the “Fourth of Never” is obviously not true. Beyond that, a future administration can use the same waiver process as the current one to further widen the scope of the possible. We doubt the next Republican president will take office on the “Fourth of Never.”

    The ACA, and those who support it, want to make sure people who earn below 138% of the poverty line get assistance with the high price of health care that they could never pay out of pocket. Period. Opposing the Medicaid expansion – in any of its forms – would deny many poor people that help. Some even oppose Arkansas’s private option. They are denying people access to the type of private insurance that most of the rest of us enjoy because, yes, we can afford it. But we do so with a lot of government money. We give people at the higher end of the socioeconomic spectrum thousands of dollars a year in tax breaks for their employer-sponsored insurance. It seems reasonable that we should be able to do this for people far less fortunate than ourselves.

    Just saying “no” is just that – saying “no”. We agree that Obamacare opponents need to do more than that. We don’t agree that they are obligated to oppose every policy option that isn’t exactly to their liking until they build a coalition in support of a preferred alternative. To conclude as much takes more reasoning than Douthat has offered.

    @aaronecarroll and @afrakt

    • The perfect is the enemy of good. The US constitution is flawed. We know it. And so did the founders. That’s why they included a procedure for amendments. Indeed, the founders believed the procedure would be used often and wisely to correct the flaws in the document. Of course, the founders were wrong. Should the founders have taken Douthat’s advice and departed Philadelphia without approving a flawed constitution in the hopes of returning later and approving a perfect one? With a weak national government and internal and external threats, would the founders have a second chance? The founders, Washington in particular, feared they wouldn’t have a second chance, and approved the constitution we have. I’m thankful they did.

      • I may be wrong but I read Douthat’s last part as a rebuttal to the blog’s claim in the first article that legitimate support for the poor compels the expansion.
        “which is stronger evidence that you want to help poor Americans, that you will support Medicaid expansion while inviting continued conversation about how to make the program more efficient and effective? Or by blocking expansion and offering alternatives, alternatives that will take well beyond 2014 to enact and implement, if they ever are?

        If you believe that
        1. medicare/medicaid is structurally unsound & inadequate for the poor
        2. Expansion dramatically cuts off the possibility of good options being implemented

        then there can be fairly strong moral case that doing nothing outweighs expansion (depending on how strong 1 is and possibility of alternatives being in place)

        Your Rev. War case seems to me to be flawed for that reason. The founders came out with an imperfect government but one they believed was structurally sound and based on the right principals. Perhaps a better idea is if the vote was to make Washington Imperator or instituting. There the country gets benefits but the government is founded on the wrong principals and it would be hard to place it on the right track after the decision had been made.

    • “one should weigh its likely inertia and imperfections against the moral implications of doing nothing.”

      This. Exactly.

    • Reading this post made me really think about the fight between ACA supporters and opponents.

      It reminded me about Chris Hedges book the Death of the Liberal Class and the topic of nonhistorical values,truth, justice, and love.

      I generally understand the right wing argument against the ACA. Generally it is based upon a hatred for Obama and a misunderstanding that it is a socialist program, which is far from the truth.

      But the support by the liberal class always struck me as a somewhat cynical; the I guess we got something, or cheerleading Obama for cheerleading’s sake.

      But it is completely consistent with Hedges thesis that “the choice is between serving human beings and serving history, between thinking ethically and thinking strategically”

      The positives of Medicaid are cost control and lack of pecuniary skimming by insurers.

      The negative is that “the poor” and “poverty” and rampant inequality is itself perpetuated by the ACA.

      Where progressives and true conservatives ( NOT neoliberals) agree is that 50 million on Food Stamps and a separate class of humans on Medicaid are not an indication of societal progress. They are an indication of societal decline.

      • The idea that opposition to ACA is “based upon a hatred for Obama and a misunderstanding that it is a socialist program” is misguided, to say the least.

        A basic fact of social life is that market based economies outperform those that are centrally planned and controlled. This is based on the “natural experiments” of the last century (not mention some that continue in this century). So if we want to help poor people, we should rely on competition, not massive government and central planning.

        In addition, healthcare is a local activity, so to the extent government is desirable, we should limit its involvement to the state level (you know, show respect for the ideas of self-government and self-determination). Yet for some reason, we’re moving to place 315 million people under the thumb of a central authority. Sorry, but to support the direction we’re headed is to support stagnation and decline for everyone.

        • “The idea that opposition to ACA is ‘based upon … a misunderstanding that it is a socialist program’ is misguided, to say the least. … Yet for some reason, we’re moving to place 315 million people under the thumb of a central authority.”

          Whether the authority is too centralized or not is a perfectly reasonable thing to debate. I’m not going to participate in it, but it should be noted that the authority is not entirely at the federal level. A good deal is in states’ hands, some aspects will be negotiated between insurers and providers, and individuals will retain considerable control over their own choices of insurance plan and receipt of care.

      • Great argument for raising minimum wage. I agree, it should go up.

    • From my perspective from the trenches of the Medicaid/Medicare billing system (tens years in hospice care, which I grant is the most straight forward of billing processes–that statement may be an oxy moron nonetheless!), I want to add that these benefit systems are evolving and changing day by day in response to federal and state nuances-preACA, interim and post. Any billing team involves coders, compliance folks, finance folks, clinical folks and so forth and all those people are interpreting the current benefit system WHILE providing hands on care to those who need it. It’s always a mess translating the complexity of the human body experiencing illness within the complexity of their constellation of support networks (ie family, friends, co-workers, etc) into codes, days of care, levels of need, etc. At least the ACA acknowledges that all should have access to the mess.

    • Robert — The one thing that cannot be amended is equal representation in the Senate

    • now matter how “philosophical he argues”, he is still complaining about politics..he does not like the legislation that was passed

    • ” It seems reasonable that we should be able to do this for people far less fortunate than ourselves.”

      If that were the case then there was no reason to pass the ACA. One would have advocated a direct method to help those poor or those falling through the cracks a way of attaining the same level of reasonable care offered to others. There was no need to pass such a complicated bill that many believe is negatively affecting them and the nation.

      • Absolutely right Emily.

        However the need, as was the financial bailout, was to preserve the status quo and the beneficiaries of the status quo. Without a mandate, toothless as it is, more healthy people recognize that the “value” proposition and risk offset aren’t that compelling and that we spend far too much on “the system” and not enough on health care itself.

        However, to quell some liberal consciences the Medicaid expansion was passed, to help the poo-er. As Mitt Romney would say. I guess it was expected that the “conservative” Supreme court decided to allow everything except for the Medicaid expansion to stay.

        I would say, we need to have a national discussion of what reasonable care is, especially toward end of life, where a significant amount of health dollars are spent.

    • It’s possible to rethink the moral basis of heathcare, and the best or next-best system for providing it, for a just society or for an unjust one. I suspect Mr. Douthat intends to do this, although he does not distinguish such fundamental questions from immediate political problems. If we interpret Mr. Douthat in this way, then his concerns are more than political obstruction. This is a generous interpretation.

      But an argument for Medicaid expansion need not address such fundamental questions. Instead, there is an ongoing healthcare system in the US, from which most people in the US derive benefits. It is miserly (also inefficient) not to extend this system to poor people as well. In the US, Medicaid is how to do this. QED

      This argument starts from the flawed healthcare system that exists. No one is obligated to argue on this basis. People are entitled to consider theoretically better systems, and moral analysis based on moral theories that people ought to endorse in making judgments about such theoretical systems.

      Also, in reply to Emily, ACA addresses many other issues in addition to healthcare for poor Americans.

    • But we do so with a lot of government money. We give people at the higher end of the socioeconomic spectrum thousands of dollars a year in tax breaks for their employer-sponsored insurance.

      First I am against the deduction for employer plans because is subsidizes over treatment but seeing that almost everyone gets those tax breaks do they disadvantage anyone? I guess the few people who are in the higher end of the socioeconomic spectrum that do not have employer sponsored plans end up paying more taxes that they should but they are few and they are not poor, the poor do not pay taxes.

      I think that we need to think of tax incidence here.

      And BTW I support a rational government provided health plan for the poor but not for the rich or middle class only for the needy.

      • The employer deduction encourages people to get their health insurance through work, which a huge percentage of Americans do. This adds another layer to the already complex set of provider, patient, insurer and — now employer.

        Second, since the average American changes jobs ever 5 years, it encourages short term-ism. Add companies changing insurers and you get churn rates (of covered individual) at 3-4 years. This means few intensive programs designed to improve the health of people with chronic diseases get a pay-off.

        Churn rates for individual insurance is higher, because as soon as people get a job with employer-provided insurance, the drop the individual.

      • The working poor do pay taxes. They likely don’t pay federal taxes, but they pay payroll, state, local, property taxes ( as part of asset inflated rent), and sales tax on most necessities.

        However when you look at the real effective tax rates the rich are paying as a percentage of income, it is the lowest in history and even going back to Reagan taxation would be an improvement. Obamas 18% effective tax rate is a joke, and giving 10% to charity is just quid-pro-quo power tactics.

        Money printing is going directly to the top 7% to encourage asset inflation and speculation. The beneficiaries of this money printing end up paying the lowest effective tax rate in modern history.

        SAO, I agree with you that minimum wages in the current system should be raised, because the current minimum wage is less the the late 70s, when taking into account inflation.

        However I think a basic income guarantee/ universal basic income guarantee/ negative income tax would be a better way to meet the objective of a less inequality and more freedom to pursue jobs that are beneficial to family and society. Decreasing jobism ( a common word in the 1920s and 30s) is important. Some jobs are bad for society, some jobs leach off society, and some jobs are bad for environment.

        • Negative income tax or the Earned Income tax credit and Medicaid allow companies like Walmart to pay salaries too low for people to live on. I’d rather Walmart had to pay higher salaries and their workers didn’t need EITC or Medicaid — ie that Walmart, not taxpayers like me, pay the difference between their current salaries and enough that they can afford health insurance and don’t need cash from the Gov’t.

      • The effective tax deduction provided by employer paid health insurance is most valuable if you are in a high income bracket. For the same $1000 of employer paid insurance an individual earning $30,000 per year gets $150 of tax benefit while an individual earning $300,000 per year gets $330 of tax benefit. So we spend twice as much in federal tax expenditures on the high income person. (Assuming that money would otherwise have been paid to both people as wages.)

    • Alsan, I mostly agree with you. Most opposition to the ACA has little or nothing to do with Obama and everything to do with what Obamacare stands for. It is a trade off of liberty for a promise that will not even be delivered in part because a lot of substance is missing from the ACA despite its great length. As you say healthcare should be handled on a more local level and that we should learn from the experiences of the last century that market based economies outperform those that are centrally planned. Despite the fact that others might accuse you of being uncaring I believe you to be very caring of the poor, future generations and the nation. It appears that you are trying to focus on how to improve life for all those groups instead of simply satisfying the voter.