What liberals get wrong about the Republican approach to health insurance
If you’re like me, your social media is filled with angry liberals. We’re angry that 24 million people will lose health coverage, the wealthy will get hundreds of billions of dollars in tax breaks, and millions of Americans with pre-existing conditions will lose access to quality care.
Yet, somehow, 217 elected representatives, and millions of citizens, do not agree with us. People will die because they cannot afford insurance or medical expenses will bankrupt them. Unfortunately, we are unable to persuade our Republican friends and colleagues that health is a right, because we have a fundamental disagreement about the nature of that right.
What do you want from a health system? If you’re like me, and turn to the World Health Organization to answer that question, you would find four health system goals: improved level and equity of health, responsiveness, social and financial risk protection, and improved efficiency. The Affordable Care Act moved us toward these goals, if somewhat imperfectly, through Medicaid expansion and exchange subsidies, banning discrimination based on pre-existing conditions, and paying providers for quality, and not quantity, of care. These goals are clearly ideological; they are based on a set of values and ideals that underpin the right to health.
In the United States, however, conservatives contest the idea that health is a right. They hold different social goals than myself or, frankly, the international community. To understand how the House could pass a bill that threatens the health and security of tens of millions of Americans, we must understand those social goals and how they influence the content of the AHCA.
In speeches and press releases, conservative lawmakers adhere to a clear, and somewhat consistent, ideologically approach that aligns with their key principles of free markets, less government regulation, and personal responsibility. Below, I’ve identified three goals that flow from those principles.
1) People should pay for their own health care or insurance.
Liberals (including myself) sometimes make fun of conservatives for, “not understanding the point of health insurance”. Obviously, insurance pays for health care for sick people with the payments of healthy people. Paul Ryan may be an easy target when he says, “The fatal conceit of Obamacare is that young and healthy people are going to go into the market and pay for the older, sicker people,” but let’s at least understand what he’s trying to say: Insurers should be able to charge health insurance premiums that reflect the insurance risk.
With the 3:1 age band in place under the Affordable Care Act, insurance companies must charge younger people more in premiums than the they consume in health care, while older people are charged less. Additionally, people with pre-existing conditions are more expensive to insure, yet insurance companies must charge them the same rates. Doing away with the age bands and pre-existing condition mandate would allow insurance premiums to better reflect the risk of insuring specific populations. Republicans didn’t pass the AHCA to hurt older people or people with pre-existing conditions, though that is the effect. They did it to better align premiums to risk, because their ideological stance points them toward less government intervention in markets.
2) Patients should have maximum flexibility when choosing insurance plans
Conservative lawmakers want maximum flexibility in health insurance. The free market, rather than the government, should decide if those plans are worth buying. The Affordable Care Act, on the other hand, set strict guidelines for the types of plans insurers could offer. It put a floor on maximum annual and lifetime insurance benefits and required all insurers to cover ten essential health benefits. Insurers could no longer offer mini-med plans or exclude specific types of benefits, like maternity care, from plans.
Instead of social and financial risk protection, their focus is on promoting personal responsibility. People should know, and purchase, their needed level of insurance. If people miscalculate that risk, then they should have done a better job of figuring out what they needed. That’s the definition of personal responsibility. In line with this principle, the AHCA encourages plan flexibility by allowing states to opt out of the ten essential health benefits and allowing insurers to reinstate lifetime limits.
3) Quality of care for those who can pay should not be sacrificed for equity
Conservatives believe that citizens are entitled to only what they can purchase, no more and no less. Attempts to ration access to care for wealthy people or people with good health insurance are unacceptable.
While conservatives will often note that the United States has, “the finest health care system in the world”, liberals like to point to life expectancy and infant mortality that are more in line with countries like Cuba and Slovakia than Norway and Canada as a counterpoint. Life expectancy and infant mortality are measures of equity, however. They look at the broad health of the population.
Conservatives are less bothered by inequality. Remember, the issue is if you can purchase quality care, not if you can access it. And at the high end, conservatives are right. If you can pay, the United States has strong survival rates for cancer patients and the top medical research facilities in the world. If you believe that quality concerns override equity ones, then rationing high end, expensive care to expand access to preventative medicine, as the ACA did, is a non-starter.
Now that we’ve diagnosed these ideological differences, where does that leave us?
The ACHA would confer benefits on younger, healthier and richer people, over older, sicker, and poorer ones. This a feature, not a bug. Younger, healthier and richer people cost less and have more money. Appeals to equity are likely to fall on deaf ears.
If the AHCA becomes law and reduces the number of people with health insurance, bankruptcies related to medical expenses will increase. Encouraging people to purchase adequate health insurance, such as through the individual mandate, however, is directly at odds with goals of personal responsibility and flexibility.
Republican willingness to trade health equity and financial protection for reduced regulation, increased flexibility, and high-end quality stem from an ideology that promotes personal responsibility, free markets, and reduced government intervention over equity, access, and risk protection. Pretending that Republicans lawmakers care about the same things that Democrats do, is a fundamental error.
While public opinion about the right to health is slowly moving in our direction, in the short term, we must either a) hold Republicans lawmakers accountable for an ideology that is broadly unpopular or b) craft policy and messaging that better appeal to those goals.
In a second post, I’ll address how Democrats can reframe the debate by changing our messaging from “benefits” to “rights” and embracing a universal, rather than means-tested, approach. To be continued…here.
