Part 3—The things which don't get said: The Affordable Care Act is the fruit of Democratic Party effort which dates, in its current iteration, to 1991.
In that year, a string of presidential candidates spoke of the need for “universal coverage.” Twenty-four years later, how is the ACA doing in that and other regards?
Last month, the ACA survived a major challenge in the Supreme Court. At the New York Times, Paul Krugman used the occasion to ask and answer that question.
“The Affordable Care Act is now in its second year of full operation; how’s it doing?” That was the question with which Krugman started his June 25 column.
“The answer is, better than even many supporters realize,” he then said.
Krugman argued strongly that the health law has been a major success. He started with the number of people who have gained insurance—and with those who haven’t:
KRUGMAN (6/25/15): Start with the act's most basic purpose, to cover the previously uninsured. Opponents of the law insisted that it would actually reduce coverage; in reality, around 15 million Americans have gained insurance.We’ll assume all those statement are accurate. In our view, Krugman is plainly describing a significant degree of success.
But isn't that a very partial success, with millions still uncovered? Well, many of those still uninsured are in that position because their state governments have refused to let the federal government enroll them in Medicaid.
Beyond that, you need to realize that the law was never intended or expected to cover everyone. Undocumented immigrants aren't eligible, and any system that doesn't enroll people automatically will see some of the population fall through the cracks. Massachusetts has had guaranteed health coverage for almost a decade, but 5 percent of its nonelderly adult population remains uninsured.
Suppose we use 5 percent uninsured as a benchmark. How much progress have we made toward getting there? In states that have implemented the act in full and expanded Medicaid, data from the Urban Institute show the uninsured falling from more than 16 percent to just 7.5 percent—that is, in year two we're already around 80 percent of the way there. Most of the way with the A.C.A.!
It could also be said that he’s describing low or lowered expectations from us in the liberal world. Here’s why we say that:
On the one hand, “universal coverage” is now said to mean 95 percent coverage. There’s no attempt to characterize the missing five percent.
Beyond that, when Krugman says we’re 80 percent of the way to that goal, he’s basically discussing the blue states. The red states have basically been dismissed from Krugman’s discussion of coverage rates. They are lagging, Krugman says, because their governors and legislatures rejected Medicaid expansion.
Without any question, that does help explain why the red states are lagging in the expansion of coverage. Beyond that, it helps explain why 21 percent of low-income adults nationwide still lack coverage, according to Gallup—a number that is horrifically bad by the norms of the developed world.
Krugman is right about the dynamics which have slowed the growth of coverage. He doesn’t explain why it’s politically possible for red-state governors and legislature to make a decision like that.
Those decisions raise a basic question you’ll never see us liberals ask. What the heck is wrong with us—what’s wrong with our political skills—when these decisions are still being made seventy years after President Truman first sought national health care—after the rest of the developed world instituted such programs?
What the heck is wrong with us? That’s a question you never see asked in the modern liberal world, where we fuel ourselves with constant talk about our own moral and intellectual greatness. As we litter the countryside with our pleasing R-, B-, N-, X-, H- and M-bombs, it simply never enters our heads that there could be something we are doing that’s slowing the nation’s progress.
Do you read the new Salon or watch our clowning cable programs? If so, you know the game we enjoy:
First, we tell the others that they’re racists, xenophobes, bigots. We then marvel at the way they refuse to do whatever we tell them next.
It’s true that the red states have rejected Medicaid expansion. We leave the second question unexplored:
Why haven’t we brilliant liberals been able to convince our fellow citizens of the folly of this refusal, seven decades after Truman? To the extent that we do ask that question, we answer it with our alphabet soup, raining our R’s, our X’s and B’s all over the countryside.
Rachel clowns, then plays with her toys. Happy, we go to bed.
As Krugman continued, he continued to praise the ACA. We don’t disagree with anything he said, but we did think he went a tiny bit partisan at one or two points.
He praised the quality of the coverage people have received—or at least, he didn’t condemn it. He said the rise in premiums has been just two percent this year, and that the rise will only be slightly higher than that next year.
He said there has been “a sharp slowdown in the growth of overall health spending, which is probably due in part to the cost-control measures” in the ACA. He said the ACA hasn’t been killing jobs.
In our view, there’s already a major point that Krugman is semi-avoiding. But as he ended his column, we thought we saw his thumb on the scale a tiny tad in a slightly tribal sense:
KRUGMAN: Finally, what about claims that health reform would cause the budget deficit to explode? In reality, the deficit has continued to decline, and the Congressional Budget Office recently reaffirmed its conclusion that repealing Obamacare would increase, not reduce, the deficit.Would repealing Obamacare increase the deficit? We assume it would, but Krugman didn’t note that this would be caused, in part, by the repeal of the taxes in the law.
Put all these things together, and what you have is a portrait of policy triumph—a law that, despite everything its opponents have done to undermine it, is achieving its goals, costing less than expected, and making the lives of millions of Americans better and more secure.
In the red states, folk do notice an omission like that. They think they’re being played.
By light-years, Krugman has been the press corps’ MVP over the past fifteen years. For that reason, we hate it when we think we see him going a tiny bit partisan.
We thought we saw that drift in this particular column. We thought that even before we saw Chris Hayes seeming to boast about the fact that our uninsured rate is now just 11.4 percent nationwide—an utterly hideous number by international norms.
In our view, we in the liberal world tend to be extremely easy on ourselves. We love to blame the others, enjoying the use of our alphabet bombs.
As droogs have done through the annals of time, we thrill to our own tribe’s moral greatness and intellectual brilliance. We recoil in horror from the fallen state, the sheer loathsomeness, of those in the other tribe.
In the case of American health care, we seldom ask if we have possibly failed in some possible way in the seventy years since Truman. Tomorrow, we’ll start to answer that question, starting with something Krugman said and moving to something he didn’t.
Tomorrow: Zeke Emanuel’s reply