Throughout Republicans’ doomed push to replace Obamacare, two words struck fear into their hearts: “CBO score.” No matter how much momentum the GOP built up for an updated bill, the Congressional Budget Office would project tens of millions of newly uninsured people and skyrocketing health-care costs, and Republicans would be on the defensive again. Democrats would express anger at the numbers; even centrists would chastise the GOP for being so cruel to so many. And what wasn’t in those headlines? The budget savings. Few Republicans dared to argue that leaving millions uninsured was just fine because the government would save money, because so many rightly saw that reasoning as morally indefensible.
In short, during the first eight months of 2017, the starting point for any assessment of a health-care plan was a moral frame: “How many people would be left uninsured, and how many people will be stuck with unaffordable bills?” After Sen. Bernie Sanders’s introduction of his Medicare for All Act, the media and political establishments regrettably have changed the debate’s starting point to “How much does it cost?” That shift is a great shame.
Moral framings should not be something one can pick and choose when to invoke. While Obamacare has had its successes, 28.5 million people remain uninsured. Is their lack of insurance any less an outrage because they are already without insurance? Similarly, that the GOP’s ideas would have increased out-of-pocket premiums by thousands of dollars was rightly seen as terribly callous. By the same logic, is it not an affront that Americans spend billions more on health care than people in other developed countries without better health outcomes? Is it now fine to deny remedies to people suffering under the country’s broken health-care system because it might save the country some money? Those who invoke morality only as a reason not to go backward, never to go forward, lose credibility on both counts.
Nor should a moral calculus be ditched on grounds of “politics.” History is littered with moral advances that party establishments slow-walked because they were cowed by poll numbers and vote counts, from the push for child labor laws and a progressive income tax in the early 1900s through the civil rights fights that continue today.
This is not to say there won’t be compromises along the way. That’s how politics works. But liberals will get more effective deals when ultimate moral goals stay central to the discussion. As Jared Bernstein wrote on Thursday, “for far too long, Democrats have way over-negotiated with themselves, starting debates where they wanted to end up.” Sanders and his allies recognize this — as reflected in their no-holds-barred defense of Obamacare this year — and are trying to change the party’s mind-set.
“But the terms of a policy debate inevitably depend on the status quo,” comes the reply. No, they are entirely arbitrary. Take, for example, the narrower question of whether universal coverage would be cheaper than the United States’ status quo. Universal-coverage supporters can point to evidence from around the world, yet detractors can only offer hypotheses why that wouldn’t work here. And yet, according to party establishments and many media outlets, the side without evidence gets taken at face value. If more liberals and (especially) centrists wanted to return to the moral calculus used earlier this year, they could do so tomorrow — and they should.
Disagreeing with the details of Sanders’s proposal is fine — there are other ways to reach the same goal within the decade. But those who argue for incrementalism, who want to make the goal more modest, should be asked: “How much longer do millions stay without insurance? How much longer do families have to deal with the insecurity of sky-high health costs? How much longer can anyone’s savings be wiped out because of one accident?” For anyone who honestly believes that lack of insurance or skyrocketing health costs is an outrage, the first question is not “How will you change the status quo?” or “Who will pay for it?” It is “How will you achieve affordable care for all?” Any other frame is a moral betrayal.