Wednesday, July 4, 2012

Whither Spite?

What we are going to see is Republican-controlled state governments refusing to expand Medicaid out of bitter hatred toward President Obama and spite for the working poor who need access to health care.
James Kwak "The Wisdom and the Absurdity in the Supreme Court's Health Care Decision" The Atlantic. Thursday, 28 June, 2012
Because, of course, it's simply not possible to see the Patient Protection and Affordable Care Act as a bad policy with negative consequences and clear costs. But before we go any farther, let me be clear - I'm not actually taking a position on the ACA. I haven't read the text of the law, and much of the ACA will take effect in rules and regulations that haven't been written yet. So I'm simply taking issue with Kwak referring to those unwilling to expand Medicaid as hateful and spiteful.

In his Baseline Scenario post on the topic, he excoriates Republican governors who appear unwilling to take up the federal government on its offer to pay 90% of the costs for new Medicaid recipients if the state adds them to their rolls. "They are willing to turn down oodles of federal money on the grounds that they need to kick in ten cents on the dollar to cover people who would otherwise go without health insurance." This criticism is disingenuous on two grounds that come immediately to mind.

The first is that "ten cents on the dollar" can be a whole lot of dollars, if the initial sum is large enough to begin with. So where does the money come from? Just as no raindrop ever feels that it is responsible for the flood, when taken by themselves, there is always enough money to fund any given policy priority, and people who push for this government program or that one often fail to account for the fact that they are not operating in a vacuum. Despite the fact that we tend to use "inexpensive" and "affordable" as synonyms, the fact that something is inexpensive does not mean that the funds to afford it are there. A 90% discount on something may be quite the bargain, but if you're already in a position where every dime you have is spoken for, it doesn't do you much good. The possible unspoken assumption that simply raising taxes is the easy answer glosses over a simple fact - raising taxes is never easy. There's a reason why, despite the fact that the Supreme Court of the United States as termed the ACA's penalty for not buying insurance coverage a tax, that both President Obama and Mitt Romney refuse to term it as such.

The second is the question of where the other 90% of the money comes from. "The federal government" is not the correct answer, unless we expect that the Federal Reserve is simply going to increase the money supply to cover the cost. The United States already borrows some 40% of its annual budget. While proponents of the ACA have always said that there would be cost savings that could be redirected to covering any new costs, but just as in anything else, it's unwise to count your money before it's hatched. So while it's easy to say that the state should treat the federal reimbursement as found money, the simple fact of the matter is that someone is going to have to pony up the tax dollars to fund the program. And governors realize that their constituents are likely to be part of that someone.

Outside of these basic questions of finance, there is also a policy question. Kwak says to governors who would face criticism from an imagined TEA Party activist for implementing the Medicaid expansion: "And, frankly, she will be right: you supported ObamaCare because it was good for the people of your state." There is a pernicious assumption here - one that is common from both sides of partisan arguments: "You know that this is a good policy - you just won't admit it." This attribution of dishonesty is not only toxic but requires some form of evidence to support it. But even if it's true, it glosses over a simple fact - good for the people of a state, and the best thing for the people of that state, may or may not be the same thing. While I tend to regard the stereotypical faith of economic conservatives that the Free Market is a nearly magical solution for any problem to be suspect, I do not go so far as to then say that this means that an expansive, activist government is any more a panacea. The idea that it's not possible to honestly consider the Patient Protection and Affordable Care Act to be bad policy, or simply not as good as another solution that someone has crafted strikes me as more rooted in ideology than in fact, especially when one considers the fact that it's genesis is rooted in certain assumptions - and not everyone shares those assumptions.

Of course, there are some pretty clear signs that opposition to some parts of the opposition to the ACA are simple political gamesmanship. It's hard to understand how the individual mandate, which was once championed by some conservatives when it came under attack in Massachusetts, is now anathema in other way than rank partisanship. Although it's worth keeping in mind that clear instances where individual conservatives were for such things before they were against them are rare (although clearly not impossible to find), so one must be careful not to fall into making charges of institutional hypocrisy, as there were some conservatives who were against the scheme from the start.

But that does not mean that any and all conservative objections to the Patient Protection and Affordable Care Act are unprincipled. We would do well to make sure that we are to hang people for inconsistency and malice that we do so with a rope woven from their own words, rather than with attributions created from whole cloth.

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