If we had to reduce the philosophical debate over health care to a single question, it would be this: Is health care a right or a privilege? As Donald Trump and congressional Republicans attempt to dismantle the Affordable Care Act and make profound changes to the entire American health-care system, the deep resistance they're encountering has its roots in the fact that they've lost that debate.
Just to be clear, that doesn't mean they won't succeed in passing their legislation. The Republican health-care bill could come up for a vote in the House as early as this week, though its prospects in the Senate are far more dim. Even without the public behind them, they may be able to push a bill through. But everything they do on health care will be judged by the standards Democrats have set, and more particularly, the goals of the ACA itself. Even Republicans themselves admit this, if you listen closely enough to what they say.
You can divide the Republican proposal into the things they want to do and the things they feel they have to do, and it's no mystery which is which. They want to roll back the ACA's taxes on the wealthy, remove the requirement for people to carry insurance, remove regulations on insurers, promote health savings accounts, and transform and then cut back Medicaid. They feel they have to offer some avenue toward coverage for those with pre-existing conditions, offer at least a little help to people who can't afford insurance, and retain popular ACA provisions like the one allowing young people to stay on their parents' plans up to age 26.
"This is sort of the problem of all of this," said Senator Rand Paul in reference to that last provision, showing an admirable candor. "People want the feel-good stuff that was in Obamacare, but they don't want to pay for it." That is indeed a problem, since the "feel-good" features of the ACA are the ones that help large numbers of people and are therefore popular. And unlike Republicans, Democrats never pretended that improving the health insurance system was going to be free. When they wrote the ACA, they paid for every dollar of new benefits with new taxes and savings squeezed from existing programs.
It wasn't cheap, and it was complicated. But the ACA has created a new set of expectations Republicans have to meet.
The first is the problem of those without insurance, which was the largest problem the ACA was meant to solve. Its success on that front has certainly been incomplete: while it reduced the ranks of the uninsured by over 20 million, there are still millions without insurance. Republicans never thought the uninsured was a problem to begin with, so it isn't a surprise that their plan would lead to tens of millions more Americans lacking coverage. But they're forced to scramble to explain why it's OK to put 24 million more Americans (according to the Congressional Budget Office's analysis) off their insurance.
The answer is to pretend that you can substitute universal coverage with something called universal "access," which in practice would mean you are legally permitted to buy insurance, provided you can afford it. "With our whole plan, every single American will have access to coverage," says Secretary of Health and Human Services Tom Price. They even try to claim that the millions of poor Americans they'd like to kick off Medicaid will be better off in the end with their new "access" to private plans they can't afford.
Or look at the ACA's requirement that insurers can't discriminate against the tens of millions of people with pre-existing conditions. This too was something Republicans never particularly cared about, but now they have to pretend they do. So they throw into their bill a way that those people will supposedly be able to have secure coverage, knowing full well that the way they do it—high-risk pools, which concentrate all the most expensive patients to insure in one pool—is doomed to failure.
Their solutions to the complex problems of insuring all Americans are so half-hearted because they've never really bothered to grapple with those problems on a practical level. Their beliefs about health care are purely philosophical, rooted in an antipathy toward government and a belief that any system that provides for everyone regardless of income must be evil at its core.
Yet they know that most Americans don't share those beliefs, particularly not in the doctrinaire version in which they prevail in today's GOP. So they have to claim that they're offering not an ideological solution but a practical one.
So to a skeptical public, they say that they oppose government involvement in health care not because they simply believe government is bad, but because government doesn't work. Any program run by the government must be inefficient and ineffective, therefore the high cost of (private) health care in America and the continued existence of people without coverage must be a product of too much government.
These practical claims are preposterous in almost all their particulars. But if they were right, then everyone, regardless of their political beliefs, could at least in theory agree with them. If a system designed by conservatives—with as little government insurance as possible and some vehicles like health savings accounts that provide tax benefits in the place of direct assistance—actually produced the best practical outcomes, even liberals would have a hard time criticizing it.
Yet conservatives have never been able to provide an explanation for why every other advanced democracy has a health care system with far more government regulation than ours yet is simpler and easier to understand and operate, insures all or nearly all its citizens, produces widespread satisfaction, and costs less than ours does. These systems vary from country to country, but none is as privatized as ours and none is as expensive as ours. If conservatives were right about the pernicious effects of government involvement in health care, then those systems would be dramatic failures while ours, with its reliance on private companies and markets, would be a spectacular success.
And if the Affordable Care Act were really the disaster Republicans claim, then the public would be demanding its opposite. They'd be demanding a smaller role for Medicaid, fewer protections from insurance company abuses, the removal of subsidies to help people buy insurance, and a reversion to the status quo ante in which those with pre-existing conditions could be denied coverage.
That's not what Republicans are promising, at least not out loud. They're saying that their plan will do all the things the ACA does, only better. And if they actually pass a bill, they'll find out the cost of making promises they had no intention of keeping.