The Best Short Summary of the Affordable Care Act (ACA) Situation You’ll Find

In a blog post called “There Will Be No Obamacare Replacement”, Paul Krugman quotes himself from seven years ago. What he says deserves to be quoted at length and shared widely.

Quote:

“You may be surprised at the evident panic now seizing Republicans, who finally — thanks to [FBI Director] James Comey and [evil dictator] Vladimir Putin — are in a position to do what they always wanted, and kill Obamacare. How can it be that they’re not ready with a replacement plan?

That is, you may be surprised if you spent the entire Obama era paying no attention to the substantive policy issues — which is a pretty good description of the Republicans, now that you think about it.

From the beginning, those of us who did think it through realized that anything like universal coverage could only be achieved in one of two ways: single payer, which was not going to be politically possible, or a three-legged stool of regulation, mandates, and subsidies. Here’s how I put it exactly 7 years ago:

Start with the proposition that we don’t want our fellow citizens denied coverage because of preexisting conditions — which is a very popular position, so much so that even conservatives generally share it, or at least pretend to.

So why not just impose community rating — no discrimination based on medical history?

Well, the answer, backed up by lots of real-world experience, is that this leads to an adverse-selection death spiral: healthy people choose to go uninsured until they get sick, leading to a poor risk pool, leading to high premiums, leading even more healthy people dropping out.

So you have to back community rating up with an individual mandate: people must be required to purchase insurance even if they don’t currently think they need it.

But what if they can’t afford insurance? Well, you have to have subsidies that cover part of premiums for lower-income Americans.

In short, you end up with the health care bill that’s about to get enacted. There’s hardly anything arbitrary about the structure: once the decision was made to rely on private insurers rather than a single-payer system — and look, single-payer wasn’t going to happen — it had to be more or less what we’re getting. It wasn’t about ideology, or greediness, it was about making the thing work.

[Still quoting the professor here] It’s actually amazing how thoroughly the right turned a blind eye to this logic, and some — maybe even a majority — are still in denial. But this is as ironclad a policy argument as I’ve ever seen; and it means that you can’t tamper with the basic structure without throwing tens of millions of people out of coverage. You can’t even scale back the spending very much — Obamacare is somewhat underfunded as is.

Will they decide to go ahead anyway, and risk opening the eyes of working-class voters to the way they’ve been scammed? I have no idea….”

End Quote.

The Affordable Care Act really was the “conservative” approach to universal health insurance, a variation on the plan signed into law by the Republican Governor of Massachusetts, Mitt Romney. But the Republican Party decided to oppose everything President Obama did. That meant they had to oppose the ACA too. Now they’re stuck trying to replace a major law they should have been in favor of all along. 

Almost final word from Prof. Krugman:

…if Republicans do end up paying a big political price for their willful policy ignorance, it couldn’t happen to more deserving people.

I’d change that last sentence to read “pay a big political price for playing extremely partisan politics with the health and well-being of the American people”, but the part about the “more deserving people” is perfect.