Tuesday, January 20, 2015

Yet more from the NEJM

Just finished writing this post when I see yet another Perspective article in the New England Journal regarding the ACA.

The Perspective article details the enormous problems for Obamacare that  a win for the plaintiffs in the Supreme Court case King v. Burwell would entail. It is clearly important to proponents of the Affordable Care Act that the plaintiff's case be weak and that the defense prevails. Indeed, the strength of the plaintiff's case is of such great consequence for Obamacare that you would think that the editors would want to see that it was covered fairly.

Here is the sentence regarding the argument at the heart of the case: "The case hinges on enigmatic statutory language that seems to link the amount of tax credits to a health plan purchased 'through an Exchange established by the State.' According to the plaintiffs in King, that language means that consumers who buy insurance through federally run exchanges don't qualify for subsidies"

The authors cannot get around the fact that the law states that only participants in exchanges established by state governments are entitled to subsidies (contrary to how the subsidies are currently being distributed).  When the authors say that the wording "seems" to link eligibility for tax credits to buying insurance through a state--rather than the federal--exchange, what they mean is that the law does make that link: they just can't bring themselves to state so plainly, hence the weak attempt to introduce uncertainty.

Of greater interest, the NEJM editors also let the word "enigmatic" slip by. Surely they could have at least provided some hint that the rationale here is not at all enigmatic. Perhaps the best way to understand the rationale is listen to Jonathon Gruber, a key architect of Obamacare, plainly lay the rationale out (lately proponents of the bill have--for obvious reasons--tried to make Gruber's role disappear). Anyone paying attention to the ACA litigation--including the NEJM editors--must be aware of the relevant Gruber videos: they received a lot of attention when they were uncovered. The linkage of subsidies to state exchanges is logical, not mysterious: the purpose is to strongly incentivize states to set up exchanges. Relevant discussions and links to the pertinent Gruber recordings can be readily found through Googling: here is one and another and a third.

Dear NEJM: please think about the balance between functioning as a journal of political advocacy and your general credibility.


  1. You nailed it, the aca crowd were to clever by half in this instance. The lefties seem ascendant in the sciences; bleed over from the social academy? I worry about the politicization of the hard sciences. Historically it has always been a mistake. I read extensively from the source files associated with east anglia climate gate. I was genuinely shocked about the anti-science culture they revealed. Further worrisome was how a large chunk of the science establishment circled the wagons. Whatever your political proclivities i would hope that scientist could over look them and oppose political agenda-driven science. disillusioned on that count.