the national interest

Do Obamacare’s Left-Wing Critics Actually Understand It?

People protest Trump administration policies that threaten the Affordable Care Act, Medicare, and Medicaid, near the Wilshire Federal Building on January 25, 2017, in Los Angeles, California. Photo: David McNew/AFP/Getty Images

Since the Obamacare wars began in 2009, Republicans have recognized the ideological stakes with perfect clarity. Obamacare constituted a substantial redistribution of resources from rich to poor (and from healthy to sick), and the party has accordingly set out to destroy it. A faction of the far left has never understood what all the fuss was about. When you look closely at the views of many of them, the reason becomes clear: They are so poorly informed on the policy that they literally fail to grasp the issues being contested.

Not long ago, I observed that the Republicans stand out among major right-of-center parties in their refusal “to subsidize medical care for those who can’t afford it themselves.” Jacobin executive editor Seth Ackerman rises to defend the honor of the Republican Party. Ackerman argues, to the contrary, that (1) Republicans don’t care much about denying insurance to the poor and sick; (2) they instead care primarily about protecting profits of the insurance industry; and (3) Democrats have more or less the same priorities. All these claims would astonish anybody who has followed Obamacare since 2009.

Ackerman begins by denying my characterization of the GOP as dedicated to denying expansions of health insurance subsidies:

Sure, that’s what the Republicans’ rhetoric says. But look, for example, at the eighteen, mostly deep-red states that refused to participate in the Obamacare Medicaid expansion. Since Obamacare began, the total number of Medicaid enrollees in those states has actually increased by 11 percent, from 18.6 million to 20.9 million, with fifteen of the eighteen states seeing increases and only two seeing decreases.

Notice that Ackerman glides right over the fact that Republican-led states have, actually, mostly refused to take part in the Medicaid expansion under Obamacare. Of course, this point that he glides past is an extremely important decision that supports my conclusion and undermines his. These states are turning down free money from the federal government, burdening not only their state budgets but also their state hospitals, which will have to eat the cost of treating the uninsured patients who show up in emergency rooms and who would have been covered courtesy of Uncle Sam. This choice shows how most Republicans are not merely indifferent to covering the poor but so actively hostile they are willing to impose pain on constituencies they do care about, just to keep the poor uninsured. Ackerman has nothing to say about this, because it would be difficult to acknowledge this fact without fatally undermining his entire case.

Instead, Ackerman perversely credits Republican-led state governments with expanding the Medicaid population while boycotting Obamacare. It is true that the non-expansion states had an increase in the Medicaid population anyway. But this had nothing to do with Republican policy or decisions. What happened is called the “woodwork effect.” Learning about Obamacare, uninsured people decided to sign up, and then discovered they were already eligible for Medicaid even without the Obamacare expansion.

Ackerman says Republicans chose to allow those sign-ups. “The Republicans who control those state governments could have slashed those numbers if they’d wanted to,” he writes. “But they don’t.” This is also false. Judy Solomon, a health-care policy expert at the Center on Budget and Policy Priorities, told me, “Most of these states cover the groups they have to cover under federal law and so legislatures or policymakers had little ability to scale back.”

Ackerman proceeds to argue that Republicans only care about insurance industry profits:

What they’re most keenly opposed to — besides any policy with the name “Obama” on it — are precisely efforts to provide public health insurance to people who otherwise might be able to afford to buy private insurance of some kind. Because that would be bad for business.

This claim is even more divorced from reality than his previous one. In the eight years since Obamacare was signed into law, Republicans have continuously taken steps that threaten insurance industry profits. Obamacare contains a series of measures to ensure the stability of the risk pool, compensating insurers who wind up with unusually sick customers. Republicans have repeatedly undermined those provisions, either legislatively, by filing lawsuits to block the payments to insurers, or (once Trump took office) simply refusing to make them. They passed a tax cut that included a repeal of the individual mandate, the provision in Obamacare that insurers most support.

The state-level Republican crusade to deny the Medicaid expansion also hurt insurers. Medicaid wound up soaking up costly patients, freeing insurers to cover a healthier population. (Two studies found this result.) That’s why, Solomon confirmed to me, “in most states [insurers] do support expansion in my experience.” The clear and consistent pattern is one of Republicans repeatedly threatening insurers, to the point of withholding payments they were legally owed, in order to prevent poor and sick people from getting insurance. It is bizarre that Ackerman concludes that the GOP doesn’t actually care about denying insurance to the poor and sick (a goal it has in fact pursued fervently) and instead cares about profits for insurers (a goal it has in fact undermined relentlessly).

Ackerman’s backwards understanding of the issue proceeds from a fixation with corporate profit — in this case, the insurance industry — as the source of all evil. It makes sense, from a left-wing ideological standpoint, that the two neoliberal parties would be united in their primary objective of protecting industry profit. It’s just not what actually happened. The a priori application of Marxist materialist principles is not an adequate substitute for reading the news. In this case, Ackerman’s obsession with corporate profit has left him indifferent to real-world human suffering that fails to comport to his neat abstract model. It is not the first time Marxists have made this error.

Do Obamacare’s Left-Wing Critics Actually Understand It?