Enough people have linked to this piece that I thought I should write a response, which you will find under the fold…
To start with a general remark. Often defenders of ACA request some kind of conservative engagement with the policy, rather than voting for the 34th (? time for outright repeal with no coherent story of replacement. I’ve laid out a coherent scenario of how ACA could evolve into something which I consider better, and actually with only modest changes to the law itself. The mandate gets narrowed, the system as a whole evolves into means-tested vouchers (which proponents such as Zeke Emanuel favor), and possibly HSAs are given a larger role again. I say states will try to limit Medicaid growth, not that they should but that probably they can over the longer run. Defenders of the current ACA don’t have to favor my analysis, but in fact what I get back is sheer annoyance from Carroll, repetition of Carroll from various others, and an attack from Krugman, with no substantive engagement on the policy proposal at all.
More specifically, he responds to Aaron Carroll’s post (hence the headline “Aaron Carroll on Medicaid Wars”). Cowen sums up Carroll’s response as “a total ‘read fail.'” Yet I think he’s sort of missing the point when Carroll writes this (my emphasis in bold):
I have a ton of respect for him [Cowen]. I think he’s an excellent blogger and writer. I’m not an economist, but economists I trust think he’s a pretty talented guy in that field, too. But I have to admit that his article set me off a bit. It could be that he didn’t have space in the NYT for more nuance. Perhaps he’ll provide it on his blog. In particular, I’d love him to address some of the points below…
Which Cowen appreciatively, if not causticly, provides. However, Carroll wasn’t responding to each point of Cowen’s piece (as I did yesterday). He was asking for the type of nuance that one should provide when predicting the downfall of a program like Medicaid. Which is to say, he wasn’t attributing his ‘annoyances’ to what Cowen specially wrote, but the assumptions that Cowen built his prediction on. Those assumptions, unsurprisingly, are widely shared (and widely stated) by the broader conservative thinking on health care reform.
Which is why Carroll writes this in his response to Cowen’s counter:
Yesterday, I was “annoyed”. That was not entirely directed at Cowen, but at the ideas that often permeate our discussion of health care policy. Krugman refers to them as “zombie ideas“, and I think that’s a pretty good description. Some of those ideas were, by my reading (yes, I read it, carefully, many times), strongly implied by Cowen’s NYT column. In his post, where he has more space to do so, he explains how and why they aren’t. Nuances matter. At the same time, many more people will have read his column than his post. So many won’t read the nuances.
[…] What bothered me were the little snippets of information along the way supporting his assertions. It’s the little ideas that many “assume” are true. It’s the justifications (often without evidence) that reinforce the ideas that annoyed me, and that’s what I wrote about.
Cowen bemoans the lack of substantive engagement on his policy suggestions for health care reform. Yet is Carroll that understands that any such suggestion for reform is greatly dependent on the assumptions underlying it. So perhaps what we have here isn’t a failure to read, but a failure to understand.