“The old order changeth,” Tennyson wrote, “yielding place to new.”
For three-quarters of a century, Americans have been debating whether the state should guarantee health coverage for all. With the passage of the Affordable Care Act, the “yes” side seemed at last to have prevailed, or nearly so. Obamacare is not quite a universal health-care program, but it shifted the U.S. closer to that outcome. For seven years, Republicans have vowed to shift it back. Now the moment for reversal has arrived. If Paul Ryan’s version of health-care reform prevails, the speaker will have accomplished something that Ronald Reagan and Margaret Thatcher never could: Repeal a fully operational social-insurance program.
But it looks increasingly unlikely that Ryan will prevail. Monday’s Congressional Budget Office estimate that 14 million Americans will lose coverage in the first year after repeal—with 7 more to lose it just in time for the 2020 presidential election—must spread panic among already nervous Republicans. Paul Ryan, a true believer, accepts that toll as the price of principle. It seems doubtful that very many other Republican officeholders will long agree.
Unlike Health and Human Services Secretary Tom Price, who absurdly promises that not one person in the United States will be rendered worse off by the GOP bill, Ryan has been commendably frank about the choice before the country. Here’s what he told CBS’s John Dickerson on Sunday, March 12.
Dickerson: How many people are going to lose coverage under this new—
Ryan: I can’t answer that question. It’s up to people. Here—here’s the premise of your question. Are you going to stop mandating people buy health insurance? People are going to do what they want to do with their lives because we believe in individual freedom in this country. So the question is, are we providing a system where people have access to health insurance if they choose to do so? And the answer is yes. But are we going to have some nice looking spreadsheet that says we, the government of the American—of the United States are going to make people buy something and, therefore, they’re all going to buy it? No. That’s the fatal conceit of Obamacare in the first place.
So it’s not our job to make people do something that they don’t want to do. It is our job to have a system where people can get universal access to affordable coverage if they choose to do so or not. That’s what we’re going to be accomplishing.
Ryan’s forthright remarks reveal the assumptions on which his policy is founded. Health-care coverage, his comments suggest, is a good that comes with a cost primarily borne by the covered individual or family. If individuals or families assesses that the good is not worth the cost, then they should be free to forgo the coverage. If that decision should ruin them financially—or expose them to life-threatening medical risk—then that is the price of freedom. As Ayn Rand wrote in The Virtue of Selfishness: “No man can have a right to impose an unchosen obligation , an unrewarded duty or an involuntary servitude on another man.” And what is a mandate but an unchosen obligation?
But Ryan’s health-care plan is encountering resistance—and, most paradoxically, the fiercest resistance from those who might be expected most to support him. Lose just three votes in the Senate, and the project stalls—maybe crashes. Despite the Republican grip on all the elected branches of government, that outcome must be accounted a real possibility, and more than a possibility.
The basis of the Republican opposition to Obamacare has gradually shifted over the past seven years. Ryan’s position—let people go uninsured if they will not or cannot pay the price of insurance—has become increasingly rare, or at least increasingly rarely articulated. Donald Trump won the Republican nomination and the presidency by promising more coverage, not less. Trump did it again at his health-care photo op on Monday: “You’ll see rates go down, down, down, and you’ll see plans go up, up, up,” he said. “You’ll have a lot of choices. You’ll have plans that nobody’s even thinking of today. They will have plans that today nobody has even thought about because the market’s going to import that with millions and millions of people wanting health care.”
Call it hucksterism and flimflam, but it’s hucksterism and flimflam that has consequences. A pair of Pew surveys in March 2016 and January 2017 found that Trump’s rhetoric has evoked a powerful response:
The belief that the government has a responsibility to ensure health coverage has increased across many groups over the past year, but the rise has been particularly striking among lower- and middle-income Republicans.
Thus, while most Republicans still reject the idea that government should ensure health coverage for all, 52 percent of Republicans with incomes below $30,000 now say that it should. Among middle-income Republicans—earning $30,000 to $75,000—the share who favor a government guarantee has jumped 20 points in less than 12 months, to 34 percent.
Even those Republicans who do not accept the principle of a government guarantee increasingly accept the practice. The uninsurance rate among non-elderly whites has dropped by almost five points since the Affordable Care Act went into effect. The declines among other groups have been steeper in percentage terms, but in absolute numbers, more poor whites gained coverage under the ACA than did any other group: almost 9 million non-elderly adults as of mid-2016. If they voted in November, they likely voted for Trump.
No wonder that Republican governors and senators, who must answer to state-wide electorates, sound increasingly queasy when they talk about ACA repeal and its Ryancare replacement. I wrote about Rand Paul last week, but he’s now seconded by many more. Those skeptics’ criticism seems increasingly based on the political risk of withdrawing coverage from those who have relied on it—and of course the House plan will withdraw coverage anywhere from millions. As they reject that risk as too hazardous, Republicans take the belated final steps on the road to universality.
And it is high time—past time!—they did so. Republicans have had too many competing goals in health-care reform. They have wanted to lower costs (to free fiscal room for tax cuts and military spending), but also to avoid tangling with entrenched health-care interests, which have decisively favored Republicans in recent years. Post-Obamacare, as before, the United States remains an outlier among advanced nations both in its absolute spending on health care and in that spending’s rate of growth. Even looking only at government expenditures, the U.S. spends a larger share of income on health care than Switzerland and Canada. That money does not buy better outcomes: if anything U.S. health-care outcomes are deteriorating.
What that money has bought is a huge and costly health sector. In 2015, Forbes rated heath technology as the single most profitable industry group in the nation, featuring a fat 21 percent margin. Loath to tangle with providers, Republicans have fixed their hopes for cost reduction on customers. “Patient-centered medicine” sought to transform the user of health-care services as the system’s decisive cost-controller. Confronted with the full cost of medicine, the patient would consume care more prudently—or forgo it altogether.
That hope is listing badly. When and if it finally sinks, Republicans may notice something else. The other advanced countries with universal coverage manage to buy significantly better outcomes at the expense of 11 or 12 percent of GDP instead of America’s 16 percent. That extra increment of GDP could pay for a lot of military spending and a lot of tax cuts. Once politics has eliminated coverage reduction as a means of forcing economy, other possibilities open before a center-right party—and indeed have opened for center-right parties across the rest of the English-speaking world. Perversely, the effort to keep government out of health care has empowered health care to consume more and more government dollars. Where government has been deployed more effectively than in the United States, health care has consumed less.
The long battle to repeal Obamacare has diverted American conservatives from their true heath-care work. The sputtering out of that battle in a completely self-inflicted failure may at last free Republicans from a doomed endeavor and liberate them to undertake the work that the country most needs from them: protecting productive enterprise and military spending from the undisciplined voracity of a health-care industry that takes too much and delivers too little.