The ACA v. the Heritage Plan: A Comparison in Chart Form

When I say that a lot of people got spun about the similarity between the Affordable Are Act, I don’t mean it as a criticism; I got spun myself. What is striking, though, in both that thread and the follow-up, is how committed anti-ACA lefties are to the ridiculous argument that the ACA is a “Republican Plan” developed by the Heritage Foundation even after presented details that make the comparison unsustainable. Perhaps it would help to present the comparison in graph form. Here, first, is an exhaustive list of the similarities between the plans:

This is, to be sure, a real overlap. It might even be a fundamental similarity in a context where the plausible alternative was a single payer or nationalized model. But that’s obviously not the plausible alternative — a statute that eliminated the American health insurance industry while steeply cutting the compensation of most medical professionals would (with the exception-that-proves-the-rule of abolishing slavery) be unprecedented in American history, and would also have no precedent in any high-veto-point system. (Even in the highly centralized Westminster systems of Canada and the U.K., in a context where comprehensive health care reform was a lot cheaper, the doctor lobby very nearly derailed universal health care and had to be bought off.) And in 2009, the idea that single payer was a viable possibility to 60 votes in the Senate requires ingesting enough hallucinogenics that you’d better have good insurance already. 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.

I should note here that some of the arguments about this point of comparison between the plans were advanced in contexts where they make more sense than “the ACA sucks because it’s a Republican Plan which proves that Barack Obama is the third and fourth term of George W. Bush nyuk nyuk nyuk.” 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.

There’s another variant, made by various people up to and including Obama itself, that notes the mandate in the Heritage plan to rebut charges that the ACA was volume 2 of the Communist Manifesto. Which, OK I guess, but I don’t endorse this line of argument, among other things because it gives Republicans too much credit and because it does begin to imply a substantive similarity between the programs even if it isn’t intended.

Which brings us to the most important dissimilarities between the plans:

This really should settle the debate. The plans are radically dissimilar. To argue that the ACA is the “Heritage Plan” is simply absurd.

Perhaps recognizing how feeble the argument is, the commenters trying to maintain the lie generally move to a bait-and-switch — when they say the ACA and Romneycare the plan passed by massive supermajorities of Masschusetts Democrats over Mitt Romney’s many vetoes are just the Republican Heritage Foundation plan, they also mean that it’s like the plan that John Chafee introduced in 1993 as a decoy alternative to Clinton’s health care reform proposal. While not as nearly progressive as the ACA — most importantly, it replaces the Medicaid expansion with medical malpractice “reform” — it is more like the ACA than the Heritage Plan. But the comparison remains transparently silly. First of all, it was of course never the “Republican alternative,” as no non-trivial number of Republicans have ever wanted to enact it (cf. every Republican-controlled house of Congress since 1994 passim.) And second, citing John Chafee — who was far to the left of the typical Republican in 1993 — as representing Republican health care policy preferences is an act of monumental bad faith, like citing David Souter as the typical Republican judicial appointment or George Wallace as having the typical civil rights policy preferences of a Great Society Democrat.

The final strategy is to just sort of throw up one’s hands at the prospect of reasoned debate. Whether the Heritage plan is meaningfully similar to the ACA is just a “subjective” matter, and if someone says that Paul Ryan’s plan to voucherize Medicare is a “variant” of the NHS because they’re both health care policies, who’s to say anyone’s bare assertion is worse than another’s? And, on some level, this is indeed a question that cannot be empirically proven to an absolute certainty. But I fully stand by my accusation of bad faith. Let’s consider a counterfactual. Let’s say the a liberal think tank developed a proposal identical to the ACA, and Bill Clinton used the power of the bully pulpit to ram in right down Congress’s throat in 1993. Barack Obama takes office in 2009 and proposes changing ClintonCare by making employee heath insurance benefits fully taxable, repealing the regulations requiring insurers to cover anything but catastrophic care, throwing many millions of people off Medicaid and devolving it further to the states, and enacting Paul Ryan’s proposal to end Medicare. Would any of the nominally left critics of the ACA be saying that Obama’s proposed changes were no big deal because they’re fundamentally just a minor variation on the Democratic, “Liberal Think Tank X” plan? Of course not — they would be leading riots against the greatest domestic betrayal by any Democratic president in at least a century, and they’d be right. Nobody really thinks that the Hertiage plan and the ACA are meaningfully similar. It’s just that some people refuse to compare the ACA to the status quo ante rather than a superior alternative that had no chance of passing, and saying that Obama just signed the “Heritage Plan” sounds a lot better than being open that your offer to the uninsured and working poor until Congress can pass the Magic Ponies and Unicorns Act of 4545 is the same as the Republican one: “nothing.”