The filmmaker Michael Moore has, through his fine documentary Sicko and other public arguments, done a great deal to bring attention to the deficiencies of the American health-care system. His New York Times op-ed on the occasion of the first day of the Affordable Care Act's exchanges repeats some of these important points. However, his essay also repeats a pernicious lie: the idea that the Affordable Care Act is essentially a Republican plan based on a Heritage Foundation blueprint. This argument is very wrong. It is both unfair to the ACA and far too fair to American conservatives.
Before explaining why a central premise of Moore's argument is wrong, let me emphasize our points of agreement. It is true that the health-care system established by the ACA remains inequitable and extremely inefficient compared to the health-care systems of every other comparable liberal democracy. Moore, unlike some critics of the ACA from the left, is also careful to note that the ACA is a substantial improvement on the status quo ante: if it's "awful" compared to the French or Canadian or British models, it's a "godsend" for many Americans. Moore also has some sensible suggestions for improving the ACA in the short term—most notably, a public option and state-level experiments in more public health care where it's politically viable.
Where Moore goes wrong is in this paragraph:
What we now call Obamacare was conceived at the Heritage Foundation, a conservative think tank, and birthed in Massachusetts by Mitt Romney, then the governor. The president took Romneycare, a program designed to keep the private insurance industry intact, and just improved some of its provisions. In effect, the president was simply trying to put lipstick on the dog in the carrier on top of Mitt Romney’s car. And we knew it.
The assertion that the ACA was "conceived" at the Heritage Foundation is simply false. I say this with no little humility—since Republicans at the national level have never actually favored any significant plan for health-care reform, I thought the content of the Heritage Plan was irrelevant, but didn't think to question claims that it was fundamentally similar to the ACA. When I actually took the time to read the Heritage plan, what I found was a proposal that was radically dissimilar to the Affordable Care Act. Had Obama proposed anything like the Heritage Plan, Moore would have been leading daily marches against it in front of the White House—and I would have been right there with him.
The argument for the similarity between the two plans depends on their one shared attribute: both contained a "mandate" requiring people to carry insurance coverage. But this basic recognition of the free-rider problem does not establish a fundamental similarity between the two plans. Compulsory insurance coverage as a way of preventing a death spiral in the insurance market when regulations compel companies to issue insurance to all applicants is hardly an invention of the Heritage Foundation. Several other countries (including Switzerland, the Netherlands, and Germany) have compulsory insurance requirements without single-payer or socialized systems. Not only are these not "Republican" models of health insurance, given the institutional realities of American politics they represent more politically viable models for future reform than the British or Canadian models.
The presence of a mandate is where the similarities between the ACA and the Heritage Plan end, and the massive remaining differences reveal the disagreement between Democrats and Republicans about the importance of access to health care for the nonaffluent. The ACA substantially tightens regulations on the health-care industry and requires that plans provide medical service while limiting out-of-pocket expenses. The Heritage Plan mandated only catastrophic plans that wouldn't cover basic medical treatment and would still entail huge expenditures for people afflicted by a medical emergency. The Affordable Care Act contained a historic expansion of Medicaid that will extend medical coverage to millions (and would have covered much more were it not for the Supreme Court), while the Heritage Plan would have diminished the federal role in Medicaid. The ACA preserves Medicare; the Heritage Plan, like the Paul Ryan plan favored by House Republicans, would have destroyed Medicare by replacing it with a voucher system.
The Affordable Care Act was not "conceived" by the Heritage Foundation: the plans are different not in degree but in kind.
Because the Heritage Foundation plan and the ACA are so different, to make his case that the ACA is fundamental plan Moore pulls a subtle bait-and-switch, comparing the ACA not only to the Heritage Plan but to the health-care reform plan passed in Massachusetts. Unlike the Heritage plan, the Massachusetts law is quite similar to the ACA, but as an argument against the ACA from the left this is neither here nor there. The problem with the comparison is the argument that the Massachusetts law was "birthed" by Mitt Romney. What has retrospectively been described as "Romneycare" is much more accurately described as a health-care plan passed by massive supermajorities of liberal Massachusetts Democrats over eight Mitt Romney vetoes (every one of which was ultimately overridden by the legislature.) Mitt Romney's strident opposition to the Affordable Care Act as the Republican candidate for president is far more representative of Republican attitudes toward health care than Romney acquiescing to health-care legislation developed in close collaboration with Ted Kennedy when he had essentially no choice.
In fairness, many liberals repeating the dishonest spin that the ACA was conceived by the Heritage Foundation have good intentions. Some, like Moore, want to emphasize the extent to which American health-care policy remain suboptimal. Some wanted to attack the ad hoc constitutional arguments developed against the individual mandate by noting that conservatives never noticed that the mandate was the greatest threat to human liberty ever conceived when the nominally favored it. But, especially with the constitutional challenge to the mandate having been resolved, the argument that the ACA is the "Heritage Plan" is not only wrong but deeply pernicious. It understates the extent to which the ACA extends access to medical care, including through single-payer insurance where it's politically viable. And it gives Republicans far, far too much credit. The Republican offer to the uninsured isn't anything like the ACA. It's "nothing." And the Republican offer to Medicare and Medicaid recipients is to deny many of them access to health care that they now receive. Progressive frustration with the ACA is understandable, but let's not pretend that anything about the law reflects the priorities of actually existing American conservatives.