Please, Let’s Not Pretend That American Conservatives Support Any Decent Health Care Reform

Paul Krugman, in the course of responding to Ross Douthat, makes what I still consider to be a bad rhetorical move:

But Ross Douthat, in the course of realistically warning his fellow conservatives that Obamacare doesn’t seem to be collapsing, goes on to tell them that they’re going to have to come up with a serious alternative.

But Obamacare IS the conservative alternative, and not just because it was originally devised at the Heritage Foundation. It’s what a health-care system that does what even conservatives say they want, like making sure that people with preexisting conditions can get coverage, has to look like if it isn’t single-payer.

As I’ve said before when noting how radically dissimilar the ACA is from the Heritage Plan, the comparison is often made by liberals with good intentions. Krugman is definitely not using the comparison to undermine the ACA because he’s incapable of strategic thought or clueless about the institutional constraints on progressive change.  His position has always been, and still is, that the ACA is inferior to European models of health care but is nonetheless a major progressive achievement that substantially improves the status quo. (Correct on both counts.) When he says that the ACA is “conservative,” he means it in this comparative sense, and fair enough, as long as we keep in mind that in the universe of American politics it’s not remotely conservative.

But I think to say that the ACA was “devised at the Heritage Foundation” just takes this argument too far. First of all, it’s simply not true — the Heritage Plan shows, in fact, that it’s perfectly possible to design something that could be vaguely called “comprehensive health care reform” that would be far more conservative than the ACA. And I particularly don’t like it because it’s far too kind to the Republican Party.

In particular, conflating the ACA with Heritage papers over what should be a central issue for the Democrats now: Medicaid. Huge numbers of people are being denied Medicaid coverage because of Republican statehouses, who are then cynically using their own obstructionism as an argument against the ACA. As the Heritage Plan — which would have, rather than expanding coverage, further devolved Medicaid (in multiple senses) to these very states — makes clear, this is not some new feature of Republican politics. And while the Supreme Court is a major villain here, the responsibility for denying mostly federally-funded Medicaid to millions of people now lies with Republican public officials. Bad as the Roberts/Kagan/Breyer compromise was, it left states with the option of taking the expansion; those that don’t need to take the blame. And Democrats need to be making these distinctions as clear as possible, not blurring them.

The reason there will never be a serious Republican alternative to the ACA isn’t because it’s impossible to propose reform that’s significantly to its right. From the Heritage Plan to this very year, there are plenty of alternatives to the ACA that are much more conservative. The real issue is the “welfare-state embedding” cited by Douthat. One of the many reasons that these Republican plans are terrible is that they would all result in huge numbers of people getting much worse insurance than they would under the ACA or none at all, and as more people sign up on the exchanges and as the less lunatic Republican states bow to the pressure of various interests and take the Medicaid expansion, this is going to become a bigger issue over time. (Republicans were perfectly rational on their own terms in trying to sabotage or kill the ACA before it could become established.) We shouldn’t let Republicans off the hook by pretending that the Heritage Plan was remotely similar to the ACA.  Their callous indifference to the interests of the uninsured is longstanding, even if we leave aside the fact that the de facto Republican alternative to the ACA isn’t Heritage but “nothing.”