Friday, March 9, 2012

ACA and 2010, Revisited

Lots of blogging talk yesterday about a new paper forthcoming from Brendan Nyhan, Eric McGhee, John Sides, Seth Masket and Steven Greene showing the effects of ACA on the 2010 elections. Their finding is that (1) the final ACA House vote seems to account for the difference between expected Democratic losses from the economy and other fundamental factors alone and the actual losses the Democrats experienced in 2010; and, (2) that the way that actually happened was that voting for ACA made a Member appear far more liberal, and therefore voters seeking to vote for the candidate ideologically closest to them flipped to the Republican. Seth explains it here; John explains it here, Brendan here, and here's the ungated paper. In my view it's an excellent contribution.

That said: I still have the same critique of it that I had when the preliminary studies were published, and which Kevin Collins tweeted, and which Jonathan Chait wrote about yesterday.

The two main points that Chait covers are: suppose that the bill failed in the House, with all vulnerable Democrats voting against it and therefore dooming it (but avoiding the effect that Nyhan et al. find). What's the effect to Barack Obama and to Democrats in general for failing to pass anything? (This one is complicated, as Chait points out, because the House had already backed the bill the first time around). That's a good question, and one which the authors themselves raise in their concluding discussion.

Or, what happens if the Democrats simply never move forward on the bill in the first place? Would some other issue simply have substituted for health care reform in GOP advertising, and thus have achieved the same effect -- and meanwhile, what damage (if any) would it have caused among liberals?

The truth is that we don't know. It's certainly possible that there was something special about health care reform that sparked such a strong reaction, and that (in the Nyhan et al. paper) convinced swing voters that Members were more liberal than they otherwise would have believed. On the other hand, it's also possible that with health care out of the picture that something else would have worked just as well.

Thinking about it...on the one hand, there's the evidence that those Members who didn't vote for ACA did not, in fact, get a substitute effect. That is, one would think that in those districts their opponents would simply plug in the stimulus, or cap-and-trade, or some provision of an appropriations bill and pound in the message that the vote for whatever it was proved that Member Smith was very liberal. Perhaps the GOP and their various candidates weren't flexible enough to do that. Or, perhaps the local advertising only worked when it was accompanied by the general  information environment we actually had. That is: no health care bill at all, and Rush and Beck and the rest pound on Substitute Issue B and therefore local advertising against Member Smith for voting Yes on B works. Given health care, and Rush and Beck and the rest bounding on it, then a lone campaign claiming that Yes on Substitute Issue B proves extreme liberalism doesn't work. Or, again, perhaps there's something particular about health care in general or the ACA in particular that's doing the work, and it's really true that without a bill, there's no effect.

That's pretty much the response that John gives this morning -- that for the Republicans, finding an effective Substitute Issue B is easier said than done. For example, on the stimulus John says "Critiques of the stimulus amounted to garden-variety “wasteful government spending.”  I’m not sure that’s as, um, stimulating as “National Socialist Health Care: The Final Solution” and “death panels” and the like."

But that raises another question. Even if it really is ACA that's doing the work, we still don't know what it is about ACA that's doing it. The mandate? The "government takeover"? The "death panels"? The Medicare cuts? The spending? The taxes? The notion that health care should be a "right"? Simply an association with Obama? Some of those would seem to sort with "liberal" more than others, but which ones were actually moving voters towards concluding that their ACA-supporting Members were very liberal? Of course, you can't do everything in one paper, so I hardly would blame the authors here for not answering that question. But without knowing what it was about ACA that was so offensive to these voters, it's very hard to know whether finding Substitute Issue B would be easy or hard. After all, ACA wasn't really a "National Socialist" scheme with "death panels." So no health care bill, and maybe those slurs or other similar ones get thrown at something else.

Basically, it seems to me that their finding supports two stories, both absolutely fascinating.

One is that health care reform, as enacted in the ACA, was a uniquely dangerous issue for House Democrats, and supporting it may have cost them the election -- through the mechanism they describe, in which supporting the bill gets translated into "too liberal."

The other is that under some conditions (such as the election of a new Democratic president and unified Democratic control), Republicans are able to use one issue to demonize mainstream Members of the House as "too" liberal. It's a limited ability; it works only when both the national information environment and local campaigns are making the same point. But the particular bill selected is incidental to the effect.

I don't see any way in what they've reported to distinguish between these two stories, both of which seem entirely plausible to me. Especially since one might suppose that the part about the GOP-influenced national information environment would be more effective in 1993 than 1977, and more effective in 2009 than 1993, given the rise of the GOP-aligned partisan press. I expect we'll get more research that with any luck will clarify some of this going forward.

UPDATE: Don't miss Eric's response below.


  1. I haven't read the paper, but it seems to me that a very large part of the Dems' problems in 2010 had to do with the combined effect of (1) misinformation about the health care law and (2) a bizarre reluctance on the part of Dems to defend the law.

    That is to say, a vote for the ACA certainly led to an electoral loss in many cases, but that wasn't necessarily true at the time the vote was taken. That was only true in an environment where "death panels" and "government takeover" falsehoods go essentially unchallenged (or at least, not challenged with anywhere near the requisite passion and vigor).

    Also, keep in mind that the ACA was sort of a "substitute issue" itself - that is, it was a substitute for a truly liberal health care reform bill that either had Medicare-for-all, or at least a public option. And the moderate nature of the ACA did absolutely nothing to temper the GOP's attacks, and nothing to diminish the effectiveness of those attacks. So I seriously doubt that the GOP would have had a problem generating outrage about some other seemingly-mundane issue.

    To me, 2010 was all about the Dems' failure to make their case. You cannot expect to take an important, controversial vote, fail to defend it aggressively, and come out clean on the other side.

  2. What Andrew said.

    Democrats didn't lose because of ACA. They lost because they allowed Republicans to create an inaccurate caricature of ACA that scared seniors. Specifically, Republicans were able to shout "Medicare cuts!" during midterm elections that traditionally are dominated by more elderly voters.

    The correct counterfactual is this: what if Democrats had carried out a nationwide ad campaign in the spring and summer of 2010 describing, concisely and accurately, what was in the ACA? And what if they had followed this up in specific districts by contrasting the ACA to hard-right Republican positions (i.e. radical cuts in everything, including Medicare)?

    I, too, haven't read the article. But by ignoring the critical role in political outcomes of strategic political/campaigning/communication choices (instead of merely binary legislative choices), it sounds to me like crappy political science.

  3. Jon:

    All great points, as usual. I just wanted to follow up with two thoughts.

    First, the idea that some other issue would have stepped up in place of ACA is a credible concern that we take seriously. That said, Republicans wildly outperformed predictions based on the fundamentals. If they had matched those predictions, one could more reasonably argue that the ACA effect was itself simply a proxy for the economy, in a "if it's not one damn thing, it's another" sort of way. But as John notes, if it was so easy to find a replacement issue, then it should have happened a lot in the past and the fundamentals would be much worse at predicting election outcomes. I certainly wouldn't rule it out, but I think one needs to be clear about the logical implications of such an argument. (Of course, if the other major bills really could have been just as potent, perhaps that just says that the Dems pushed through a lot of unpopular stuff.)

    Second, the argument that the Democrats would have been punished for *not* passing ACA seems a lot less credible to me. To believe that the Democrats would have done just as poorly under that scenario, you need to believe that Republican and independent voters would have been *more* angry with vulnerable Democrats who cast a "no" when the bill failed than they were with similar "no"-voting incumbents when the bill passed. Either that, or Democratic voters would have had to punish their Democratic incumbents for failing to support the bill by voting for a Republican candidate who never supported the bill in the first place.

    Of course, there's always the prospect of turnout effects: Democrats would have been so disheartened that they just wouldn't have shown up at the polls. Might be, but I think the research shows that such effects are generally a lot smaller than the simple effect of changing the minds of people who are already going to show up.

    In sum, I can believe that the exact effect of ACA on seats was smaller than we estimate (in fact, our own estimate is expressed in terms of probability, not certainty), but I think it's more of a stretch to say ACA didn't have a significant negative effect on Democratic fortunes.


  4. I agree with the comments above, and also this:

    After all, ACA wasn't really a "National Socialist" scheme with "death panels." So no health care bill, and maybe those slurs or other similar ones get thrown at something else.

    ACA seems like a very good test case precisely because it was, originally, a Republican-designed and -backed policy. If something like that can be caricatured as socialism, then anything can. Particularly, as Andrew says, if Democrats decline to defend their own position.


    1. Another sub-hypothesis is that health care / ACA was not, in fact, a uniquely dangerous issue for Democrats, but they mistakenly THOUGHT it was and acted accordingly.

    2. When Sides says, "Critiques of the stimulus amounted to garden-variety 'wasteful government spending.' I’m not sure that’s as, um, stimulating as 'National Socialist Health Care: The Final Solution' and 'death panels' and the like," he's just not thinking creatively. Or rather, he's still assuming that GOP / Tea Party critiques somehow rose from objective facts about the policies being critiqued, instead of conjuring those facts out of thin air. Had ACA not already been available for this purpose, the stimulus offered a wealth of opportunities to discover signs of incipient fascist takeover. Recall that 2009-10 featured Glenn Beck screaming about "White House czars" and linking Obama and ACORN to Hitler via Woodrow Wilson (?!). Monetary easing was the target of apocalyptic attacks, even though that wasn't even directly Obama's doing.

    The point is, it was all but certain that unified Dem government under the first black president would be a target of absolute hysteria, regardless of the policy particulars. I'm not sure Obama could have escaped this even if he had governed like a conservative Republican -- because even that would be exercising power, and any use of power can always be pictured as the Death of Liberty if that's what people want to do. (I can easily imagine a counterfactual in which, deprived of all else, the Right had turned against the Bush-era antiterror surveillance / detention / Patriot Act policies -- the closest thing to actual dictatorial policies on offer -- and begun pretending that these were somehow Obama's creation, as they're now pretending that the job losses of late 2008 and early 2009 were somehow his fault.)

  5. Losing the House but gaining some semblance of a national health care system (even taking into account that it is heavily watered down from what would be ideal in order to win enough votes to pass) was a worthwhile trade off to me. Democrats can always win back the House perhaps as soon as this year. Opportunities to pass a national health care bill are far rarer. We elect members of Congress to work on solving national problems not to perpetuate themselves in office forever and ever by never casting votes that might imperil their re-election.

    1. Yes. When Democrats first started talking about taking back the House in 2012, I dismissed it as wishful thinking of the most pathetic sort. That was before the passage of Ryancare, which changed my mind. I still think it's a long shot (though not an unprecedented one--it's basically what happened in 1948), but if it does happen, there will be something deliciously ironic about that.

  6. Andrew and Anonymous may well be right, but I wonder if there any examples where Democrats, or anyone, were able to turn around public opinion on an important issue by making voters smarter. Old Silver-tongue Clinton's health reform died without a vote, partly due to a misinformation campaign. The Civil Rights Act led to a partisan realignment in the South - would a better PR campaign have kept the Southerners in the Dem fold, perhaps even short-circuiting a lot of the animus that lingered (and lingers still) after the bill was passed?

    FDR introduced the Social Security Act with a statement read by a clerk, and then mentioned it once in a press conference and once in a radio address, and it passed, by a wide margin. No sales job necessary, just as it was not particularly hard for FDR to turn around public opinion on the
    necessity of declaring war on the Axis, which required just one speech and a quote which will live in fame.

    Finally, in a country where about 20% of GOP voters believe that Obama is an atheist-Muslim-Kenyan-Socialist-Fascist-Ayers/Dorhn lovechild, there's definitely a ceiling as to how many people you can convince with facts and reason.

    1. ". . . which required just one speech and a quote which will live in fame."

      I think Pearl Harbor may have played a role in that as well.

  7. I was writing that last comment of mine when Eric McGhee posted. I do think, as I just said, that it was "easy to find a replacement issue," and that this in effect DID happen in the past, at least under Clinton, where things like haircuts and Travel Offices were trumped up as big issues. And if it's happening even more easily now, that's probably because of the rise of partisan media, the breakdown of some of the old conventions that kept politicians from lying quite as blatantly, and -- lest we forget -- the fact that the current president IS BLACK, people. (Not to blame everything on that, but poli-sci analyses that ignore it are kind of missing the forest, y'know?)

    Second, before assessing the scenario in which the bill failed, our political-scientist friends should re-read what savvy commentators like Chait were saying at the time. Dems had already voted once for the ACA, so voting it down later would not have shielded them from attacks over it. The narrative would have been: They TRIED to impose a fascistic socialist takeover of health care with death panels, but heroic Republicans forced them to back down. Plus, it would have made Dems look ineffectual, like they couldn't get things done even on their own terms. In other words, they would have had the worst of both worlds. That's why they would have done "just as poorly under that scenario," if not even worse.

  8. Dems in 2009-10 had to do SOMETHING with their majorities or the Dem base would have rebelled - not just carped from the sidelines about flaws in ACA, but possibly have gone truly, righteously nuts, at least as nuts as Tea Partiers yelling and protesting.

    Maybe under some theories, that would have been a good thing, who knows - I doubt it, and it's a pointless fantasy. The point is that the Prez and the DemCong wouldn't have just been sitting around on their thumbs. To sustain the counterfactual: If they weren't going to fulfill a major campaign promise and historical Dem goal, they would have had to compensate with truly major action on jobs or maybe accelerated withdrawal from Iraq and Afghanistan or indictments of Wall St malefactors or all put together.

    Instead, arguably quite wisely from a long-term and practial perspective, they spent a big portion of their capital on ACA, and the real - not "professional left" imaginary/ideal - correlation of forces, the real total state of American ideology and political possibility ca. 2009-10, led to ACA as we know it rather than, say, Single Payer or something else more classically social-democratic (also fast-acting, on-budget expensive, etc.) on the one hand, or, on the other hand, something less likely to impact actual insured-rates at least over the middle term.

    ACA as actually constructed, and not yet completely implemented or fought out, is a mirror of the real state of political play in the U.S. of A. Chait's criticisms reflect that fact. The study is not completely useless, but, as ever, lends itself to naive, pseudo-scientific applications.

  9. I am sure that real HCR, with a public option, or Medicare for All, would have driven to the polls the silent scores of millions who presently opt out of politics because real progressive policies and real progressive politicians, are never offered to them, and in such numbers that the GOP would not only not have taken the House, but would have had their minority further reduced, perhaps to 1934-36 levels.

    Or maybe I just read too many lefty blogs.

    1. I assume (hope) you're being sarcastic.

      The Democrats most tarnished by the 2010 elections were the Blue Dogs and others in reddish districts (such as Alan Grayson). A public option (which would not have been anything close to Medicare for all) might have marginally increased progressive turnout, but I doubt it would have done much more than that, if at all. More than likely, progressives would have found plenty of other things in the bill to complain about, anyway.

    2. Could you specify more precise grounds for your sureness, DXM? How do you know that these silent millions (or even scores of millions!) exist? How do you know that they would have emerged to vote this time, as opposed to all the other times when they passed by on the other side of the road?

  10. They have to exist. There's no other explanation for why Republicans don't lose every election by Alf-Langdoneque margins except massive non-voting by tens of millions of people hoping for better than what they're offered.

    The alternative -- that tens of millions of people don't care that much because they don't care that much, or that they might actually prefer the GOP alternative -- just beggars the imagination.

    1. Come now, haven't you come into contact with many people over the course of your life who are almost dispositionally apolitical and un-ideological, uninterested in those matters and not inclined to take any time considering them? I have extended family members like this, co-workers like this, etc. I'm sure you do too. There are many forms of apathy, and some form of inchoate leftism/liberalism is only one of them, a portion, not the entirety. It seems pretty clear to me that it's difficult to actually politicize and motivate people who aren't naturally so or aren't well enough off to have the time to devote a bit of thought to it.

    2. I'm bad at picking up on sarcasm, but I think we're seeing it here, PF.

  11. The ACA addresses the problem of health care inequality in this country, no? In a pre-ACA environment, we are a nation of ~75% world class health care, and ~25% third world health care. Though the ACA itself won't necessarily get us there, it is certainly the first step toward bridging that gap.

    Bridging that gap means normalizing health care, either legislatively (or defacto) as a socialized system would. AFAICT, there are no conceivable budgetary assumptions in which said normalization would occur at the Cadillac levels currently enjoyed by the majority of Americans who are beneficiaries of heavily-subsidized big group insurance.

    And so, either 1) the ACA specifically or 2) the legislation that follows stands to impose a real cost on the majority of Americans. This does not make it a bad thing. Arguably those Americans are currently beneficiaries of unreasonably good health care provision, particularly given how little their fellow citizens at the bottom receive. But in any event, there will be a cost - no one denies this, do they?

    And unless you are an ideological supporter of progressive health care dreams, you won't like those costs, will you? Why must we look any further than this to understand the larger-than-expected price paid by the Dems in 2010? Even though we dislike conspiracy theories, when a parsimonious explanation is staring us in the face (people punish politicians who threaten to take something away from them) this conversation is replete with fanciful interpretations of Republican mind-control and manipulation, conning folks who will surely benefit (!?!?) from the ACA into thinking they won't.

    Which is all sort of disheartening in a sense. Everyone recognizes that Congress faces the daunting challenge of evolving into an era of taking stuff away for the good of the country, after nearly breaking the country on a century of giving away more than we could afford. Liberals should be proud of the last Congress for starting this process with the somewhat-painful but nevertheless-necessary ACA.

    Instead, the universal reaction from the partisan left is that the feared pain is not real but rather Rush Limbaugh's trick.

    And y'all think we have what it takes to curb the explosive growth of Medicare down the road!?!?

    1. I don't think this is quite right. The liberal view of health-care reform is not that it's somewhat painful but nevertheless necessary. It's that the U.S. system is gigantically wasteful and badly tilted toward enriching private interests rather than delivering actual health care. The more socialized systems of other nations have demonstrated that better outcomes could be delivered to patients at lower cost if:

      1. free-riding was eliminated;

      2. various proven (and a few unproven) "best practices" were adopted; and

      3. overhead costs were reduced.

      Nationalized systems are the simplest and most efficient way to do all this, which is why Medicare and the VA (and systems abroad) deliver more health care per dollar spent, and why the Right fights tooth and nail against creating even government insurance plans (the "public option") that people wouldn't have to buy, but that would compete on price against the absurd bloat that is private insurance. Our system wastes immense amounts of money on things like private insurers' and drug companies' TV advertising campaigns and, notoriously, on the mechanisms needed to cherry-pick the healthiest customers and deny coverage to others. It manages, in effect, to charge people for the privilege of treating them cruelly.

      So, ACA addresses #1 by getting everyone into the system; per capita, the cost of insurance goes down as risk is spread among healthier people who would otherwise choose not to participate. It addresses #2 with various "duh!" sorts of reforms, like making medical records electronic and easily transferable so, for instance, my buddy who's a cardiac patient doesn't have to personally pick up a DVD from one doctor's office and drive it to another's (actual recent story). Also, it sets up mechanisms for figuring out which treatments are actually effective and focusing health delivery on those. This is also the key to curbing that explosive growth of Medicare you mention, as is smart, reasonable end-of-life planning (aka "death panels"). Our current system doesn't create incentives for adopting such best practices, because there's profit to be made in NOT doing so. Relying on the profit motive is one huge perverse incentive.

      Sadly, #3 isn't addressed as well as it should be. The ACA system will still depend on, and greatly enrich, private insurance companies. But, looking ahead, that's the next step -- either creating a public option or nationalizing more of the system over time. I expect that eventually, and in our good ol' bloated, inefficient American way, we will lurch toward a system resembling Switzerland's.

      (to be continued.....)

    2. Overwrote my word limit. Anyway.... It's true that the political economy of all this is complicated, and that there are, in any big reform, inevitably winners and losers. But there is scant evidence that ordinary people will be among the losers, as opposed to the rentier class that currently makes a pile out of the inefficiencies of private insurance. What Limbaugh, Palin and the GOP did in the health-reform debate was convince average citizens that pain imposed on the 1% is actually harm to the 99%. That IS a trick, and it's one the Right has been deploying for decades, at least since Reagan called lavisishing money on the wealthy "the people's tax cut." The other thing they did was lie about what the reforms would do, treating commonsensical cost savings as "death panels" and whatnot.

      There may come a time when the government's job will be to "take stuff away for the good of the country," but I don't think ACA puts us there yet, and I think most liberals would add that that day can be postponed for some good while if we just restored reasonable progressivity to the tax system -- raised upper-end rates, as most Americans support doing, reversed cuts to estate taxes that affect only the wealthy, etc. That's the great debate we're currently having. For thirty years the Right has been winning it, and they've been very clever about both playing on and aggravating a peculiarly American suspicion that government is always bad. But the tide may be turning. The old, bloated "free market" ways of doing things are becoming an indulgence we can't afford without seriously cutting benefits for normal people, and the rise of people like Romney is dramatizing the real, one-percentish interests that drive GOP policy. And when people finally see this, they don't like it.

    3. Jeff, thanks for taking up my argument; this is an interesting discussion. A few thoughts, maybe I'll add some more tomorrow:

      First, I think its quite likely that a universal health care system in the US would, as you suggest, bring down cost per capita and perhaps provide better care per capita as well. However, the US health care system is unusual in at least one respect, since there is currently such a dramatically bimodal experience in consumption. If we standardize the system (eliminate the modes), the result may be better than the average of the current system...and still quite a bit worse than one mode, perhaps the place where the unusual quantity of Republican Congressional votes in 2010 emerged.

      I can't recall the cite, but one of the think tanks gave the NHS in Britain a B- for cancer care, a grade noticeably worse than the "A" attributed to American large group insurance for cancer care. But, the organization added, the B- was a heck of a lot better than the F you would experience if you were on the fringe of health care in the US.

      "B-" may indeed be better than the average of A and F; for the Fs, a B- looks like a dream. For the A's; however, a B- looks like a vote for a Republican Congressional candidate.

      Finally, I think its important not to make too much of stuff like overhead, etc. The US does not spend a disproportionately greater amount on health care than any other developed country because we don't have e-MARs. The problem is not that your buddy is responsible for toting his chest x-rays around. Its that, assuming he's the beneficiary of large group insurance, his access to world class heart treatment is surely better than any other country in the world. If he doesn't have such insurance, his luck will almost certainly not be nearly as good.

      In closing, you know what would be telling to this discussion? A poll of Americans with large group health insurance, asking how many would gladly trade that coverage for insurance under something like Britain's NHS. I bet almost none of them would.

      Which may be a delusion on their part, an ephemera that is going to go away anyway, but it would pretty well explain the 2010 midterms, it seems to me.

    4. Yes, I completely agree that a well-constructed poll could give us some useful information here. How closely correlated were / are people's votes with their actual likely gains or losses under ACA? Obviously I'm hypothesizing that the correlation isn't close, but I'd be open to counter-evidence on that if we could agree on what to test for. For instance, I don't believe ACA-type reforms will drive down current outcomes for the better positioned from A to B-. I might buy A to A-, but anyway we would need to nail that down. Another thing is that the poll would need to take account of intangible but real benefits, like eliminating the possibility that you'll lose coverage altogether or have it denied just when it's needed. That's the greatest perversity in our current system, and it's why the law in question wasn't, technically, ACA but PPACA, the "Patient Protection and Affordable Care Act." What are people willing to pay for patient protection? Would they, say, refuse a deal in which their general coverage declines a bit, or costs a bit more, but is guaranteed for life? Or would they rather have an A that could become an F next week? We're talking about Americans here, so I really don't know; selfishness and short-sightedness are honored traditions in this country. But at any rate, I agree this is an empirical question on which more data would be useful.

    5. I tend to agree that normalization of HC in the US would net out at a level higher than the NHS or average Canadian provincial system - for several reasons, not least because the current landed health care gentry in the US would tolerate nothing less.

      But the higher national levels of service won't come without a cost; so we're kind of crossing our fingers and putting our faith in significant innovation. I can't say anything more; its a moot point and I have no special expertise on the likelihood of such innovation.

      I suspect that many Americans among that landed HC gentry are aware that the increasing strain on their large group health providers portends bad things to come for them - if they respond by sticking their heads in the sand (and, in 2010, voting Republican) this should, as you note, not be a surprise - but not necessarily a sign of particular American weakness but rather flawed human nature.

      Finally, I forgot to mention this last time: my personal policy preference is for returning everyone to Clinton-era rates; actually, I'd even accept increasing everyone's rates a couple dozen basis points above the Clinton levels.

      But that would count as Congress imposing a cost, no? The cost of diminished disposable income. At a minimum, its an awfully tricky road ahead for the US.

    6. I was half-kidding about American selfishness and short-sightedness. But only half: I do think there are cultural traditions that make Americans, in general, more anti-communitarian and less willing to pay even small costs for much bigger overall or long-term gains. I was once a member of a focus group on airline service that was asked how much we'd extra we'd be willing to pay for an LA to NYC flight (5 hours) if it meant an improvement in service from Southwest Airlines quality to something resembling a luxury cruise on the Queen Elizabeth II. Nearly everyone rejected the idea of paying any more than $25 for that vastly better treatment. Ultra-low price was all.

      Long way 'round to saying: Yes, it will impose costs to raise taxes, but if this were done properly most people would scarcely feel it. The demagogic trick they keep falling for is letting spokesmen for the 1% convince them that the more visible pain to be visited on that tiny group would be everyone's. But, that's the argument that will continue to be made, so as you say: tricky road ahead.

    7. I do think there are cultural traditions that make Americans, in general, more anti-communitarian and less willing to pay even small costs for much bigger overall or long-term gains.

      I probably mentioned once or twice that my lovely wife is originally Canadian, and further that I'm an American who lived several years in the Great White North.

      Having a foot in both cultures, I'm still surprised at how demographically similar we are, and at the same time how different: I think your quote captures a big part of said difference.

  12. To add to what CSH said, we must also remember that the ACA represented a large scale expansion of federal government power at a time when Americans were extremely sour on that concept. The public had seen a stimulus that appeared, from a man on the street perspective, to cost a lot and help very little. It had seen banks, car companies, and insurance groups be rewarded for bad behavior at public expense. Now the same inept bunch that had allowed that were taking over a sixth of the economy? It is not a great mystery why many people reacted so strongly. People wanted clear and effective action on jobs, not social reorganization. I am not claiming these perspectives were right, far from it, but I don't think the anger was a mystery.

  13. This has been an interesting discussion. On CSH's point about normalization, that does seem to be a likely consequence, but I don't think it's correct (if this is what you're doing) to think of it as bringing both ends of the spectrum to some arithmetic mean. Even if a floor is added to health care at the low end (a worthwhile goal in itself), the system will remain unequal. Even if there are longer lines at the doctor's office because more people can now go, there will still be people who are able to cut to the head of the line or have a separate line to themselves. But there probably is a sizable mass in the middle who are concerned about their standards being reduced--perhaps a system that goes from A & F to A & B & C, a real gain for people at the bottom, an overall gain for society, but a reduction for certain subsets in the middle. (Eventually, we may train more doctors, if the incentives are right, but that will be a while.)

    1. I think this is an important point to add, and one I glossed over previously: its not at all clear what HCR will finally look like in the US; its not obvious that it will be similar to the Canadian or British socialized systems.

      We could just as easily evolve toward something such as what Scott describes: for lack of a better term, perhaps it is a version of Rawlsian distributed justice applied to health care (no one better off unless the lowest person is better off).

      This is important because there is a big difference for the landed US HC gentry between full-on Canadian/British socialized medicine and the Rawlsian-type outcome Scott describes. What's more, the ball is very much up in the air wrt where the US shakes out.

      And thus, what seems like irrational frenzied opposition to the ACA, including the unusual dumping of liberal congressmen, may in fact be fairly mundane maneuvering, or an effort to increase the likelihood that the system settles out in an advantageous way for a particular set of stakeholders.

    2. What Scott said, and what Jeff said above about people perhaps not embracing a deal in which their own "normal" care is slightly less gold-plated but is always guaranteed, even though it appears to be a very good deal.

      But as I said in the post, I'd be very, very cautious about drawing "why" conclusions without more information. There's a real chance that what's driving all of this is death panels + Medicare cuts, and there's also a chance it's all Obama-related.

    3. I don't disagree with that. I was just rambling off on a tangent, to wit, I don't assume everyone is going to come out with the same level of care. After all, it's not really socialized medicine. On the other hand, I don't assume that this is the reason some people dislike it. People don't know enough about it to have such a precise objection.

      On another tangent, people often speak of socialized medicine as what they have in Britain or Canada. Britain has socialized medicine, where the doctors work for the government (akin to signing everyone up for the VA). Canada has socialized health insurance (akin to signing everyone up for Medicare), which is actually run by the provincial governments (although I imagine there are federal standards).

  14. I don't see how the ACA could be unique in this. It wasn't the only party-line issue to be voted upon, and since it was party-line, how exactly are they telling that it was the ACA and not party-affiliation? So few didn't vote against it, and of those, more of those who voted against it and were democrat lost than those who voted for it and list. Unless you make an arbitrary determination of which weren't safe at all.

    And what about the huge reduction in turnout? All Republicans in Congress garnered nearly twenty million votes less than Obama did two years prior. That's a huge lack of turnout.

    How would not passing the ACA have helped that at all? Did they compare it to 2006 turnout? What?

    1. It wasn't really party-line for Dems in the House; there were enough "no" votes that it was possible to do the study.

      As far as turnout: the study doesn't really speak to that, but IMO doesn't need to. What matters are the differences between voters/districts in which Dems voted yes vs. Dems voted no.


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