How much do the healthiest people in society owe to the most vulnerable?
That question—about Americans’ capacity for shared sacrifice—was at the core of the struggle over repealing the Affordable Care Act during the first months of Donald Trump’s presidency. Now, it’s resurfacing in the escalating partisan debate over responding to the coronavirus crisis.
In designing the ACA, then-President Barack Obama and congressional Democrats put a premium on policies that encouraged more sharing of medical and financial risk among those with greater and fewer health needs, such as requiring insurers to guarantee coverage to consumers with preexisting conditions. During the repeal fight in 2017, Trump and congressional Republicans condemned those same efforts, arguing that the law required the young and healthy to sacrifice too much to reduce the risk to the old and sick.
A similar divergence is emerging as the country grapples with the social and economic strain of containing the rapidly intensifying outbreak. In his public comments this week, Trump—amplifying a chorus of conservative economists, elected officials, and media figures—has effectively argued that shutting down the economy is imposing financial pain on more people than can be justified by the number of lives the restrictions will save. Democratic governors, such as New York’s Andrew Cuomo, counter that the broader society has an obligation to save as many of the most vulnerable as it can, whatever the pain to the many. “Job one has to be to save lives,” Cuomo declared in a video he released Tuesday. “We are going to fight every way we can to save every life that we can.”
These contrasting perspectives place the parties in the same position they were in not only during the recent attempts at repeal but also during the initial debate over passing the ACA in 2009. “It absolutely is a parallel there,” says Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. “It’s very much about the social compact and how much cost do I have to incur to help my neighbor, who may be in greater need than I am?”
The geographic distribution of the disease in its early stages reinforces the parties’ philosophical split over the basic question Corlette raises. So far in the United States, the disease has primarily clustered in large metropolitan areas, with New York City, Seattle, San Francisco, Los Angeles, New Orleans, Chicago, Miami, Boston, and Detroit among the places bearing the heaviest brunt of the outbreak. In every state, voters in and around cities have become the Democratic Party’s foundation.
By contrast, the disease has made significantly fewer inroads in small-town and rural communities that have become the central pillars of the GOP coalition, especially under Trump. That disparate level of exposure means that many Republican-leaning areas feel the effect of the response to the disease more than they do that of the disease itself, notes Larry Levitt, the executive vice president for health policy at the nonpartisan Kaiser Family Foundation. And that makes such places a receptive audience for Trump’s argument that the cure cannot be worse than the problem. “At this moment, the economic crisis is much more visible in redder parts of the country, while the health crisis is more visible in bluer parts of the country,” Levitt says.
This conflict is unfolding most tangibly in several of the nation’s largest Republican-leaning states. In Florida, Georgia, Texas, and Missouri, for example, local officials in big Democratic-leaning cities (such as Miami, Atlanta, Dallas, and St. Louis) have moved to severely restrict activity. But those mayors have complained that their efforts are being undercut by the refusal of Republican governors—whose support is typically greatest in rural areas—to impose uniform limits across the state.
This tension may preview the larger collision coming if Trump, supported by an array of conservative leaders, moves forward on his calls to begin lifting limits on Americans’ behavior, an action most Democrats and many public-health officials resist as dangerously premature.
How to apportion risk across society is an issue that underpins many of the most pointed conflicts between the parties, even if it is rarely discussed explicitly. As I wrote in 2017, promoting the sharing of risk between the healthy and the sick was a preeminent goal of the ACA. Before the law, people with significant health needs were either charged much higher premiums for coverage in the individual-insurance market, or denied coverage altogether because they had a preexisting condition. Those rules benefited healthier people buying individual coverage: Because those with greater needs were systematically excluded, insurers had to pay out fewer claims, allowing them to hold down premiums for everyone else.
The ACA upended that arrangement. Through a long list of reforms, it required insurers to sell coverage at comparable prices to those with greater and lesser health needs—a policy known as “community rating.” It asked the young and healthy to pay more for coverage so that it would be affordable, and available, for older and sicker consumers.
The widespread lockdowns now being implemented to contain the spread of the coronavirus rest on the same underlying principle. In even the most adverse scenarios, most Americans will not be seriously sickened or killed by the disease. That means the nation is now imposing costs on many people who are less likely to die of the coronavirus, in order to reduce the risk for those who are the most vulnerable.
“The discussion we are having now about the coronavirus epidemic is community rating writ large,” Levitt says. “It’s about making a sacrifice in order to protect people who are old or have a preexisting condition and therefore have a higher risk.”
During the ACA-repeal fight, the Republican alternatives to the law all sought to reduce premiums by unraveling parts of the law related to greater risk sharing. Since the repeal effort failed, the Trump administration has continued to pursue that vision through regulatory measures. For instance, it has allowed the sale of more short-term insurance plans, which provide fewer benefits at lower cost and lure healthy consumers away from shared-risk pools with the sick.
“A critical difference between the parties” is this, Corlette says: Democrats believe that “the healthy should subsidize the sick—the young, the old—because we all get older and sicker at some point in our lives.
“On the flip side,” she continued, “if you look at what’s underpinning many of the more conservative health-reform ideas … [it’s that] what people pay toward their insurance or their care should reflect their level of risk.”
That perspective applied to the coronavirus outbreak means that individuals or regions that are at less risk can be asked to sacrifice only so much to protect those at greater risk. Texas Lieutenant Governor Dan Patrick expressed perhaps the most extreme version of that thinking this week when he argued on Fox News that older Americans would accept a greater danger of dying from the disease if it allowed the economy and the broader society to reopen sooner.
Trump and other conservatives are marching toward that same policy conclusion, even if they are using less incendiary language. Down one front, they argue that shutting down the economy carries its own health dangers, because a sustained economic slowdown will seed more suicides, alcohol and drug abuse, and domestic violence. And down another, they insist that government always must balance the cost of saving lives against the economic consequences of its decisions.
Stephen Moore, a former economic adviser to Trump, and one of the most vocal proponents of reopening the country, notes that the federal government already puts a price on life when it evaluates the costs and benefits of environmental or occupational health regulations. The same logic should apply to the outbreak. “There are costs to all of these things,” he told me. “The idea that we are going to keep the economy closed for seven or 10 or 12 weeks or more is untenable.”
Moore acknowledged that evaluating the costs and benefits isn’t easy, because the failure to quickly develop and deploy testing has left America blind to how many cases it’s now facing—and thus uncertain about how many deaths it might confront from loosening restrictions sooner rather than later. (“We are shooting in the dark here,” he conceded.) But, he argued, under any scenario, there must be some balancing of economic and public-health costs. While it might be a natural instinct “to destroy the economy of New York City to save a few hundred lives,” Moore insisted, “that’s not necessarily the right decision, because you have 7 million people who are going to be severely hurt.”
The biggest paradox in the health-care fight was that the Republican efforts to unravel risk-sharing hurt the material interests of their electoral coalition. The reason is that all their plans raised costs on older people with greater health needs at the same time as their base was becoming older and whiter. Their plans lowered prices for younger people, who now lean reliably toward the Democrats.
In some ways, the effects of quickly reopening the country might not follow partisan lines as consistently. Demographically, it might benefit some Democratic-leaning constituencies (low-wage workers of color vulnerable to a sustained economic shutdown, for instance) and imperil some Republican-leaning ones (such as seniors). But the geographic implications are much more straightforward, with the outbreak, so far, concentrated in Democratic-leaning major metro areas, not Republican-leaning regions. If the disease was now ravaging small-town America, it’s unlikely that Trump and so many other conservatives would be as enthusiastic about easing social distancing.
The reprieve may be temporary: Most experts believe it is only a matter of time until the disease reaches throughout the nation. “This is going to continue to roll out over the country over the next months,” Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told me. “You would expect the metropolitan areas … that have the most international travel to be where the virus is first introduced. But that then is just a seeding event for areas around the country.”
The likelihood that the disease will steadily advance beyond its beachheads raises the final parallel to the ACA fight.
The law’s proponents believed it was in the self-interest of the young to pay more to ensure coverage for the old, because the former hope to eventually become the latter. Conservatives now questioning whether they are paying too great an economic cost are, in fact, in the same position as young people under the ACA. They are prepaying on measures designed to better contain the disease before it comes to the smaller places Republicans rely on.
It’s not too surprising to see Trump and other Republicans bridle against social distancing: Their complaints fit with the right’s long-standing unease about any policy that shares risk by imposing costs broadly. The entrenched power of that belief is why Corlette is pessimistic the country will preserve widespread limits on activity while the disease remains concentrated in relatively few places. “I have zero optimism we will be able to sustain that,” she says. “It may be sustained in pockets of the country, certain states or certain cities. But it’s hard to see this nationwide for much longer. As a country, we are not great at embracing the social contract.”
The growing recoil on the right from social distancing suggests that she’s correct. Unless and until the disease widely disperses, it’s not hard to imagine Trump and other conservatives eventually describing the disease as just a problem of big cities, the way they’ve already labeled it as the “Chinese virus.” Loosening rules on activity while criticizing the places where the disease is still raging might prove an effective near-term strategy for rallying Trump’s political base. But in terms of protecting public health, abandoning a common front against the disease may prove the riskiest course—including for the smaller communities yet to feel its bite.
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