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As Senate Republicans go through the valley of the shadow of death for their health-care plan, questions are again being raised about what they really want. Is it lower premiums for individual health insurance, particularly for the people (presumably many of them Republicans) who aren’t poor enough to qualify for Obamacare’s purchasing subsidies? Is it “entitlement reform,” focused on rolling back the Affordable Care Act’s Medicaid expansion and then capping that program’s growth forever as a government-shrinking exercise? Is all the talk about health policy really just a disguise, as many liberals suspect, for an agenda of high-end tax cuts and low-end spending cuts that have little or nothing to do with Obamacare?
The answers to these questions may be as various as the micro-factions of the GOP in Congress, and a lot of the answers most definitely lack coherence. But one policy impulse shared by some conservatives is important to understand because it encourages a very destructive attitude toward the existing health-care system. Some conservatives really just don’t like the idea of health insurance as we know it.
This has again become apparent in some of the senatorial reactions to the Congressional Budget Office’s estimates of how many Americans (22 million) would lose health insurance under the Better Care Reconciliation Act. Here’s the classic from the number-two Republican in the Senate, John Cornyn:
He wants to celebrate the “freedom” of Americans to go without health insurance, though he surely understands most of the 22 million would not “choose” this option if affordable health insurance was available.
That’s not as exotic a belief as you might imagine. Conservatives have long believed that “third-party” health insurance — health insurance provided by employers or the government — encourages over-utilization of health services and thus is responsible for high rates of medical inflation. And many believe the only legitimate purpose of health insurance should be to cover catastrophic costs, not the routine medical services that people used to pay out-of-pocket in the days before a combination of tax subsidies, collective bargaining, and employer competition made employer-sponsored comprehensive insurance plans common.
So, unsurprisingly, most conservatives who can be coaxed into a discussion of their actual aims propose getting rid of or expanding to individuals the tax subsidy for employer-sponsored health plans, to reduce the incentive to access care whenever you think you need it. And they envision a system in which everyone pays for routine care via a tax-preferred health savings account — basically paying the doc out-of-pocket the way Americans did back in the Good Old Days of individual responsibility — and has a relatively cheap catastrophic-care policy to cover life-threatening conditions.
Whether you find this vision frightening or invigorating, it is clearly very different not only from the Obamacare status quo, but from the status quo ante long before Obamacare. This longing for really old-school health-care policy causes all sorts of political problems for the Republicans that harbor it. For one thing, it cuts against the hatred of high out-of-pocket costs that unites most middle-class folks regardless of party or ideology. And for another, as Cornyn has learned, treating comprehensive health insurance as a socialistic vice corrosive of American values just does not accord with the actual values of actual Americans.
At the moment, Republicans clearly do not have the power or the popular support to impose an early-1950s vision of health care on the country. They nonetheless fight every feature of the health-care system that involves spreading the risk — and the cost — of poor health, which is the basic function of private as well as “government” health care. It might clear the air and foster a real health-care policy debate if conservatives would just come out and admit they oppose health insurance as we know it. But it does not sound like much of a winning message for 2018.