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.