Principled Opposition and the Affordable Care Act

[rowyn]

A recurring sentiment I keep seeing on Twitter is 'Those conservatives oppose the ACA because they want poor people to suffer!' That's about the nicest way I see it phrased. Most of the other ways are more hyperbolic. 'I didn't think that real evil -- the kind of monsters who want to make people suffer -- existed on a large scale in the world. But then I realized a large fraction of the voting population wants the ACA repealed.'

I don't feel strongly about the ACA, to be honest. It's of modest personal benefit to me in a few ways. I suppose there are people who choose their policy positions based on whether or not those policies benefit them personally. I have never been that person. I want my government's policies to benefit the population as a whole.

Here are my health care ideals:

* Incentivize high quality care
* Incentivize the development and exploitation of effective new treatments, drugs, vaccines, etc.
* Incentivize breakthroughs: revolutionary care
* Disincentivize fraudulent and ineffective treatments, drugs, etc.
* Make high-quality care accessible to everyone

These are all good things.

They cannot all be accomplished simultaneously. You cannot just push all the sliders to 100% and Acheivement Unlocked: Perfect Healthcare.

You can minmax it. Regulation deters fraud (good!), and it also slows and sometimes prevents innovation (bad!) But all regulation is not created equal. You want the regulations that do the most good and the least harm. It is totally possible to make regulations that do no good (unless you count 'protecting the market of existent companies' as a good) and lots of harm. It's not possible to make regulation that does zero harm, but that doesn't mean it can't be minimized.

The truth is, health care in the real world has long since passed the point where I have any clue what policies are doing best on my sliders above. I don't really want to argue the specific details of the ACA or health care policies.

Mostly what I want to say is:

* I do not think people are evil and selfish if they want the ACA repealed. Most of them believe one or more of the following:
-- the free market will encourage more smart, dedicated people to enter and remain in healthcare professions.
-- heavy government regulation leads to corruption
-- the free market will provide a wider variety of healthcare options for more people
-- the free market will encourage more innovation and advancement in healthcare.

Likewise:

* I do not think people are evil and selfish if they want the ACA to continue. They believe one or more of the following:
-- the ACA helps more people get access to care
-- healthcare in the US without the ACA was a balkanized disaster that left tens of millions uninsured and was an accounting nightmare for medical professionals and financially ruinous for the ill and really anything is an improvement.
-- government involvement in healthcare will not deter innovation and/or will spur it. And/or innovation is less important than access.

My point is not "the arguments for each side above are all true and if you disagree with them you are an idiot". They may all be wrong! But people who believe them are not evil or stupid or insane. They are acting on a combination of facts and heuristics to try to encompass an enormously complicated system.

I am personally okay with the ACA being repealed or not. I can't tell how much good vs bad it is doing and feel like it's probably roughly equal.

I am pretty sure I have said all this before, more eloquently and with more evidence, and all the people who say "the only reason anyone opposes the ACA is because they think poor people deserve to die" are going to ignore me this time too.

So I guess I am writing this whole rant for the three people who already know everything in it but just want to hear someone else say it. So they know they're not alone. So they know not everyone on the Internet thinks they're evil monsters.

You're not an evil monster. It's okay.

Comments

[elbren]

the countries that have the best outcomes and the lowest cost have a mixed private/public system, where basic care is available to everyone at public expense, and the citizenry can pay for elective/faster/alternative health services if they have the resources and want to. poor outcomes and high cost? that'd be the system we had before aca.
we've never had a free market in health care since health insurance became widely adopted, and won't even after aca protections are repealed. just try to get a price quote in advance for any medical procedure.
so, with aca we have broader access and some of the benefits of a public system.
without aca, we don't even get the benefits of a free market system, because insurers don't work that way.

[greylistening.livejournal.com]

Thank you for this post, Rowyn. It is novel to hear someone say, "You are not a monster" about anyone, anywhere on the internet these days.

I could not support ACA because it was making my son's access to health care worse and worse, health care he needs to survive.

But I do not demonize anyone who supports ACA because it does good things for them or their family. How could I?

[tagryn]

Good post.

* I can say, I have one relative that works in medical billing, and another who is a doctor. They both hate the ACA, as I understand it because it created a maze of regulations which didn't improve care of patients in any meaningful way. I know the doctors I talk to lament how much time they have to take away from patients to make sure their record keeping is complete, just so that they can get paid. Electronic records held a lot of promise that AFAIK hasn't panned out to date.

* On Twitter, I have a number of people I follow regularly who would be directly and negatively impacted if the preexisting conditions clause went away. I'm deeply sympathetic, while also recognizing that emotional testimony along the lines of "my son will DIE if we can't afford his medicine!" is perhaps not the best way to guide public policy that affects millions upon millions of people. Then again, if it were someone I loved who couldn't afford their medicine, I really wouldn't give a d**n if premium increases were making health insurance increasingly unaffordable for large groups of people I didn't know. I'd want that insurance, end of discussion. I'd also probably view the people who wanted to take that away very personally as people who wanted my kid to die; there's certainly enough of that going around on the Twitter these days, too. Again, very understandable, but not the basis for any kind of discussion.

* My very basic understanding about ACA is that they had enough political capital to deal with one of two problems: either fix lack of coverage, or fix ballooning costs. The first got (mostly) fixed, while the second is threatening to swallow those gains. The best ACA could manage was enacting some promising pilot projects to see what might work at controlling costs; larger reforms, like tort reform, were off the table.

* Even the story of how the ACA got passed varies considerably, depending on which "side" you listen to. To the Democrats, it was a vital needed reform of a dying system that the GOP refused to go along out of spite, despite it borrowing heavily from Republican plans like Romneycare...and then couldn't be reformed where needed because of GOP stubbornness. To the GOP, ACA is a convoluted mess ("we need to vote on it before we can find out what's in it") that was rammed through without the usual compromises between the parties, and is too fundamentally flawed to be saved; they also note that their previous plans to reform the HC system pre-ACA were blocked by the other party.