Everyone is entitled to his own opinion, but not his own facts. Founded by Mark Kleiman (1951-2019)
It’s a little early, but Steve Benen may have uncorked the classic line of the 2010s.
I know it’s early, but I’ll go out on a limb and say that Steve Benen has uncorked the classic line of the 2010s:
If you were to make a Venn Diagram of the issues Tea Party members care about, and the issues Tea Party members are confused about, you’d only see one circle.
And thank Hermes there are bloggers out there who do their readers the credit of assuming we know what a Venn diagram is.
ACA’s “mandates” revisited: fallacies of choice and honesty about benefits.
My post last week on the Affordable Care Act got a lot of attention. Left Blogistan mostly liked it, though Kevin Drum asked the right question about framing. The other side not only didn’t like it, but thought I was lying. I’ll try to answer Kevin, and in the process explain what I think about the others.
Quick recap: I said it was rhetorically awful to describe ACA as an “individual mandate” because that stresses the least attractive and least significant thing about it. I proposed, instead, this description:
If you or your family aren’t getting health insurance through your job, the government will pay to get you private insurance coverage, just as an employer would. You’ll have to contribute something—but the law guarantees, with specific numbers, that it will be no more than you can afford.
..with a bit more.
First, Kevin’s question (he actually has three, but the last one sums up the other two pretty well):
In real life, how would this work? Once we reel off Andy’s paragraph, the next question from the Fox News anchor interviewing you is still going to be, “But it’s not voluntary, is it? You have to get insurance whether you like it or not, right?” What’s the answer?
Here’s my answer:
That’s just the way things work now for people who get insurance through work. Most people get health insurance along with their paycheck whether they ask for it or not. Most of them don’t get a choice of insurance, the way they will under the government-brokered exchanges in ACA. Very few have the option of turning down the insurance and getting cash instead—and if they could, very few would. ACA just gives people who don’t have insurance through work the same chance to have health insurance that people get if they do—and no less choice.
This is a folk version of the central left-liberal claim: we love choice and liberty just as much as the libertarians, often more, but the government is not the only enemy of choice and liberty. Before ACA, people didn’t get to choose their health plans: the employer chose. If you valued your job, you were stuck with the health plan your boss liked, not the one you would have liked. (This is still true under ACA, and I wish it weren’t. It will become less true if private employers start to drop their health insurance, as Kevin and I both think would be peachy; insurance shouldn’t track employment anyway.)  Before ACA, if you hated your job but had even a slight health condition, your choice of quitting was effectively foreclosed: you couldn’t go into business for yourself if you wanted insurance. Before ACA, people with pre-existing conditions who didn’t have jobs with health insurance—maybe because they were, for example, very sick—had no “choice” of health insurance at all: none was available at a remotely affordable price.
As this is America, I don’t expect to win these arguments in the abstract. I expect to win them by analogy. Most people don’t currently experience the health insurance market as a realm of liberty and choice. People who have to buy insurance on the individual market have the kind of “liberty” they wouldn’t wish on anyone (unless they’re quite young and very healthy—the people who least need insurance, and whose outrage, frankly, concerns me relatively little). Those who get insurance through their employer take the plan they’re given, and if they get good health care out of it, they’re pretty satisfied. ACA simply makes the government into the same good-enough insurance provider that many employers are now, with no less choice than most people have now. The insured have to pay part of the cost—but again, that’s something most people experience with their private employers right now.
The libertarians act as if most people wish they were in the pre-ACA individual health insurance market. If that’s right, my frame will fail. But I think it’s wildly wrong. Most people wish they had the kind of jobs that provided good health insurance. They don’t want maximum choice, which the status quo ante can’t offer them anyway. They want good health care.
This relates to my answer to those—like Left Coast Rebel/Conservative Generation, Professor Bainbridge, and TrogloPundit—who think that I’m denying the law involves a mandate. I admit that my original post used an abstruse form of punctuation called quotation marks; some therefore didn’t get that by saying ACA wasn’t a “mandate” I meant that it wasn’t best described as a mandate, not that it wasn’t one. Of course the law mandates that everyone have insurance, under penalty of law (though the extra 16,000 IRS agents are, once again, a complete fabrication; in fact, under ACA, the usual penalties for violating tax laws, like liens, will not apply). That’s what laws do. They mandate things. Sending my kid to school, obeying the speed limit, paying my research assistants the minimum wage, participating in Social Security: all are “individual mandates,” if you want to portray them that way. But portraying them that way is a bizarre libertarian frame. It emphasizes the fact that laws exist on these matters but not the reasons they exist, the substance of the benefits that they aim at. A focus on the consequences for those who defy the mandate is also technically accurate but conceptually perverse. If I disobey any law, the government will come after me. In fact, if I flout the mandate that I use the government-run currency, as opposed to one blessed by the free market, the Secret Service will come after me. But most people pretty much avoid such consequences—by obeying the law. The free-marketeers are, ironically, evading personal responsibility on a massive scale. Anybody who chooses to break the law that covers health insurance, will be treated as a lawbreaker. But whose fault is that?
Short version: I know full well that ACA contains a mandate. But I don’t care; I don’t think anyone else should care; and I think that once they get used to the new law and hear it explained properly, nobody much will care. That’s why turning the debate away from mandates towards the fact that everyone will now have government-paid health insurance isn’t denial. It’s honesty.
Update: Organizing for America shows how the “more choice” frame is done.
What’s a synonym for “mandate plus a subsidy”? Government buys you insurance, with a small contribution. Let’s put it the second way.
My post on why the ACA will become popular was too long and confusing. Shorter me:
The phrase “individual mandate,” though it explained to wonks how we were going to achieve near-universal coverage, was always bound to make for atrocious framing. Pairing it with a subsidy is great policy but possibly even worse framing. Now one thing people don’t like—being told by the government what to do—is supposed to be made better by another thing they don’t like—admitting they need government help.
Here is another way of describing ACA that’s completely accurate but explains the point much better:
“If you or your family aren’t getting health insurance through your job, the government will pay to get you private insurance coverage, just as an employer would. You’ll have to contribute something—but the law guarantees, with specific numbers, that it will be no more than you can afford. It’ll be less than three percent of your paycheck if your family makes $33,000 a year, less than ten percent if you make as much as $88,000. Pre-existing conditions won’t matter. The government will still pay for your insurance, with the same affordable contribution from you.”
The bill has lots more—things that make it even better. But that, it seems to me, is the basic idea. And if we drill it in, people (Fox News junkies aside) will stop imagining that the bill is somehow about government telling people without insurance that they have to get it because the government won’t help them. It’s the opposite. Under ACA, it’s the government’s job to get you insurance, and to pay for almost all of it if you can’t afford it. Before, you were on your own.
Objections? Can we sink the “mandate” language once and for all? And can anyone explain to me whether (or why) anybody ever though “individual mandate” sounded good politically?
The middle class adores its government benefits as long as the programs reward work. ACA does.
Andy wonders whether the American middle class will accept government benefits. I think that they will, and already do.
And this because, as Andy rightfully suggests, the issue has been framed deftly. People think of Social Security and Medicare as insurance, not as a government benefit. They think that they have paid for it.
Now, it’s trickier with ACA, because not everyone benefits from it. Social Security and Medicare are universal, whereas ACA by itself is not.
So perhaps the programs that can best be compared to ACA are Food Stamps, Unemployment Insurance, and the Earned Income Tax Credit. the latter two only go to working people, and Food Stamps mostly goes to working people. They have been stable and generally politiically robust. in the case of Stamps, the agriculture industry has played an important role in its vitality, a role that with ACA in the future will probably be played by private insurers getting customers off the exchange.
There is one more big advantage for ACA: it is much harder to stigmatize it as a handout. Liberals never understood that the public hated and still hates “welfare” because it is unconditional cash assistance. It is far from unreasonable to think that unconditional cash assistance destroys the work ethic.
Health insurance is different. Perhaps I am overly optimistic on this, but I would guess that the public understands that getting health coverage doesn’t destroy someone’s work ethic or desire to better onesself. FDR famously called poor relief a “narcotic”; I can’t see anyone outside the Tea Partiers believing the same thing.Â
The woman in the story that Andy references might think so, but let us remember: the Tea Partiers aren’t America. They just claim to be. And this woman is really an outlier: she says that Social Security doesn’t work well. Let the GOP run on that. Go ahead; make my day.
Some people irrationally hate the Affordable Care Act because they irrationally think that government programs that they like don’t count as government. But time solves that problem.
Steve Benen notes a story about a Dallas woman with cancer who owes her life to an array of government programs—unemployment insurance, COBRA—yet still opposes the Affordable Care Act because she’s anti-government. This leads Steve to lament the success of unhinged Beckian rhetoric: “many of those who stand to benefit from a stronger safety net have been led to believe they want a weaker one.”
The story is actually half as worrying as Steve portrays it, but twice as strange. Scroll down in the original story and you get this:
When the severance benefits and other subsidies are gone, Amy said, the family might have to look – reluctantly – at some of the options contained in the new health care law.
“If I get to the point where we couldn’t afford to pay [for health insurance] maybe that would be a safety net,” she said. “But if they force you to pay and you can’t afford it, then you are back where you were.”
Note two things:
(1) This person is talking about a bill that’s mostly about subsidizing health insurance for working- to middle-class people so they can afford it (and avoid emergency-room induced bankruptcy), and blaming it for making her buy insurance she couldn’t afford. Fox News has sold a fair number people on the idea that the law contains mandates but no subsidies. But this is surely something that can be solved through education. Even the mainstream media can’t ignore this forever. It’s big, it isn’t subtle, and aside from pre-existing conditions, it’s the main point of the bill. If you’re unemployed* and uninsured, the government will pay for your insurance. If your income is up to 133 percent of the poverty level, you’ll get Medicaid. If it’s at 150 percent of the poverty level (roughly $33,000 a year for a family of four), your insurance premiums won’t be more than 3-4 percent of your income. If it’s as high as $88,000, four times poverty level, they’ll be no more than 9.5 percent. All this won’t kick in for a few years (nor will the mandate to buy insurance). But is that a reason to oppose it now?
I’m amazed that the point I’ve just put in bold hasn’t been made a selling point so far. But that won’t last forever. I’ll keep flogging it in this space if no one else will. (That’s a threat.)
(2) The woman in the story hates government programs, doesn’t think she’s using any government programs, yet would accept a government program if she had to. This merely confirms Arthur Schlesinger’s old dictum that Americans are ideological conservatives but operational liberals [Update: he was citing Lloyd Free and Hadley Cantril: see comments by Derek below]—except that things have become more radical. As Mnemosyne, one of Kevin’s commenters, notes, “most of these people seem to have convinced themselves that the government programs they’re taking advantage of are somehow not actually government programs.”
But this is a problem that solves itself, though in a way that will make liberals gnash our teeth in frustration. Once ACA becomes familiar, it will be popular, irrevocable—and unlikely to be perceived as the product of government. It will be added to the long list of government programs—public schools and universities, interstate highways, Social Security, Medicare, the military—that are politically impregnable because they no longer scan as government programs but rather as the background noise of everyday life. Government initiatives become popular in America not when people consciously value and affirm them but when people stop noticing them.
Denial is not the highest road to an adequate welfare state. But it’s a road. I’ll take it.
*or employed by a company that doesn’t provide health coverage—but that makes the slogan too long. Perhaps regrettably, I think security is a much better selling point than universal coverage. Most people think—insanely, but given our customs, very durably— that health insurance ought to be employer-based, and don’t like the idea that they’ll have jobs while government pays their insurance. But they’ll get used to the latter state too, once they have it.
Update: I guess I disagree with Jonathan (who was writing his post at the same time I was writing mine) on this. Maybe government support for the middle class is very popular—though I think it’s double-edged and must be sold deftly, since the U.S. middle class bristles at the idea that it needs government support. (Taking a subsidy is one thing. Admitting that one needs to is another.)  But I’m willing to be persuaded. And if I am, I’ll strike “unemployed and” from the slogan above.