With the release of the House leadership’s plan to repeal and replace the Affordable Care Act, Republicans suddenly find themselves having to answer a lot of questions about health care, which they’re not exactly comfortable doing. In the process, they’re revealing something important: not so much the details of their plan, but the values that underlie it.
Those values, and the clash between the different ones different players in this issue hold, will determine whether compromises can be reached or whether the whole thing goes down in flames.
Yesterday, Rep. Jason Chaffetz got in trouble for saying that people who lack health insurance ought to just consider not buying an iPhone. And today, the director the Trump administration’s budget office, Mick Mulvaney, said this in an interview with Mark Halperin on MSNBC:
HALPERIN: “What’s your range of estimate of how many fewer people will have health insurance?”
MULVANEY: “We’re looking at it in a different way, Mark, because insurance is not really the end goal here. It’s one of the conservatives’, one of the Republicans’ complaints about the Affordable Care Act from the very beginning, it was a great way to get insurance, and a lousy way to be able to actually go to the doctor. So we’re choosing instead to look at what we think is more important to ordinary people: Can they afford to go to the doctor? We’re absolutely convinced it will be more possible for more people to get better care at the doctor under this plan than it was under Obamacare.”
This is basically gibberish. How is it that when people no longer have insurance, they can “get better care at the doctor” than they do when they have insurance? Nevertheless, it’s edifying to have a top administration official say plainly that insuring people is not their goal, and if a lot of people lose the coverage they now have, then that’s okay with them. So let’s run down some of the basic value clashes at work here, and how they’re being expressed in policy.
Democrats want to see everyone insured; Republicans don’t. Getting as close as possible to universal coverage was the most important goal of the ACA when Democrats passed it. But as Republicans are making clear, having large numbers of Americans without insurance simply doesn’t bother them. They say they want “universal access,” which is essentially meaningless, since you don’t have “access” to something you can’t pay for.
Democrats see health care as a collective responsibility; Republicans see it as an individual responsibility. Democrats accept the fundamental premise of insurance, which is that risk is spread throughout the population and inevitably some people pay for others, in the same way that we all pay for schools even if we don’t have kids or pay for a fire department even if our house never catches fire. Republicans want to leave it up to everyone whether they have insurance or not, and if you don’t, that’s your choice.
Democrats are more concerned with equality while Republicans are more concerned with individual freedom. Democrats would like to see a system where everyone has the same access to health care, which is why they like Medicare. There’s nothing Republicans find more horrifying than a system where rich and poor get the same benefits, which is why so many of their preferred mechanisms — like health savings accounts — are better for you the more money you have. Democrats want to force insurers to provide good coverage, which is why the ACA mandated a set of minimum benefits that plans have to include. Republicans want to do away with that mandate and let insurers sell plans as skimpy as they can get away with, like they used to.
Democrats are happy to have government provide insurance; Republicans aren’t. Democrats look at the millions of people who have been insured by the ACA’s expansion of Medicaid and say, “That’s great! Now all those people have coverage.” Republicans look at it and say, “That’s awful! Now all those people are sucking off government.” They would literally rather see a poor person be uninsured than see them get insurance from the government. Though they know they can’t dismantle Medicaid entirely, their goal is to get as many people off it as possible.
Republican see poverty as a moral failing, and will only grudgingly accept benefits given to poor people. One of the biggest dangers to the Republican bill comes from a potential revolt by the ultra-conservative Freedom Caucus, which is terribly distressed by the fact that the Ryan bill is insufficiently cruel to poor people. Republicans are insistent that states be given “flexibility” in Medicaid, which in practice is the flexibility to cut benefits and kick people off the program. They’d also like to impose things like work requirements, so that if you can’t find work they can take your health coverage away, too, or drug testing, just to offer you a bit of humiliation along with the benefit (you’ll notice that they’re aren’t asking anyone to pee into a cup in order to get the mortgage interest deduction).
Democrats are fine with income redistribution; Republicans aren’t. The ACA did many things, but at its heart was a plan to greatly expand coverage among the poor and middle class, paid for by increasing taxes on the wealthy. Republicans find this abhorrent, so they are now trying to roll it back, taking away coverage from the poor and middle class to pay for a tax cut for the wealthy.
Those are just some of the value clashes now playing out, and Republicans have to decide just how far they’re willing to let their values take them. They have at multiple points stepped back from the logical expression of those values, every time because they realized how unpopular that expression would be. They’ve had to include some (stingy) subsidies in their plan as a nod to the idea that people should be helped by the government to afford coverage, much as it pains them. They had to come up with a complex, jerry-rigged solution to the problem of those with pre-existing conditions, a problem they never much cared about before the ACA addressed it. They said they’d delay the revocation of the Medicaid expansion by a few years (past the midterm elections!), because they’re afraid of the blowback from millions of people losing their coverage.
But the clash of values is what will determine whether they pass a reform bill at all. Back in 2010, there were Democrats who disliked the ACA because it didn’t go far enough. But their desire to expand coverage was strong enough to make them willing to set aside that disappointment and support the bill. What we don’t yet know is what happens to Republicans when it’s time to vote. Will the conservatives say that something like the Ryan bill is too generous to the undeserving and too far from free-market purity? Will it make them bolt, preferring to see nothing pass rather than approve a bill that makes some compromises?
There’s one thing we do know: President Trump has no particular opinion about any of this. What he says about health care is driven not by his values but by a momentary assessment of what sounds popular (“We’re going to have insurance for everybody“). Republicans can’t count on him to be an effective salesman for their bill, or even to keep supporting it when the going gets rough. And it’s already gotten rough.