Conservatism and health care

The Senate today held a vote on a procedural measure that would allow for debates and amendments on, well, something. No one is quite sure what measures will be debated and amended, This Vox explainer did a nice job of helping me understand what’s going on. The final vote was 50-50, with Vice-President Mike Pence performing his one constitutional duty by breaking the tie. There was also some high drama, as Senator John McCain, recently diagnosed with brain cancer, nonetheless showed up and voted. He then gave a powerful, stirring speech, in which he launched an all-out attack on the bill he had just voted for. “I will not vote for this bill,” he said in a powerful, if wavering voice. Uh, okay.

I’m hardly the first person to point this out, but Republicans currently control the House, the Senate, the White House, and likely hold a 5-4 advantage on most Supreme Court votes. And after voting to repeal Obamacare a jillion times when Obama was President, they can’t seem to pass a health care bill now. No Democrats will vote for a bill repealing the single most important legislative achievement of the Obama administration, though Democrats do have bills ready for a vote that would fix the problems the ACA undoubtedly has. But those bills will never be allowed on the floor for debate or votes. Republicans have made it clear that they have no interest in bi-partisan cooperation on health care. And they haven’t been able to get much done. Today’s vote in the Senate was procedural. Will it lead to a final bill? Probably not, but you never know. I certainly hope not; every bill out there, including the House bill that passed, the Senate bill that didn’t pass, and the various bills under current consideration, all of them are terrible bills. If the goal is to expand the numbers of Americans with adequate access to affordable health care, these bills all fail. In fact, they fail pretty spectacularly. They reduce the numbers of healthy people buying insurance through the ACA exchanges. They cut Medicaid. They will take health insurance from 20 to 25 to 35 million Americans. Which means, in all likelihood, that people will die.

As a loyal Democrat, it’s tempting to conclude that these bad bills exist because Republicans are bad people. These bills are variously described as ‘mean-spirited,’ ‘cruel,’ vicious’ and ‘lethal.’ The implication is that Republicans are uniquely indifferent to basic human suffering. Republicans want to cut taxes for rich people. (They always want to cut taxes, and rich people pay higher taxes than poor people). And in these debates, they always look terrible, like a party of nasty, uncaring Scrooges, out to hurt, or even kill poor people. Of course, they try to defend their various bills, insisting that CBO scores are wrong, that poor people won’t lose their insurance, that what they’re doing is allowing states more flexibility and providing people with more freedom. It never works. They look terrible in every instance. These are historically unpopular bills.

I don’t think, though, that Republicans are meaner than Democrats. I think that’s a dangerously hubristic way of looking at it. Preening about our moral superiority is a temptation most progressives have given into at least occasionally. But it isn’t true. There are philosophical differences between the parties, and we’re never going to get anything done if we insist that those differences are also moral. I know lots of Republicans. Good folks. They’re just real bad at health care policy.

And the reason isn’t hard-heartedness or indifference to suffering. It’s conservatism. Republicans tend to be conservatives, and a lot of Republicans are deeply committed, ideologically conservative. In fact, I believe that Republicans are far more committed to ideological conservatism than most Democrats are to ideological progressivism, which I don’t think is even a thing. You will often hear Republicans, talking about some policy or another, say things like ‘that policy is incompatible with the basic principles of conservatism.’ I’ve never heard a Democrat say the equivalent. Never once.

If you know enough conservatives, and you listen long enough, you’ll hear them admit to this: they don’t think health care is a right. They think health insurance is a commodity, like any other commodity. If you can afford it, great. If you can’t, well, then live without it. If you get seriously sick, and don’t have insurance, there are any number of charitable organizations that can help out. (And in my experience, Republicans give generously to those charities). When we talk about universal health care, conservatives don’t believe it’s something government can or should provide. Big government, the federal government, is inefficient, corrupt and overly expensive. Putting government in charge of health care is likely to hurt a health care system that generally works pretty well. And Obamacare doesn’t just expand health care, it mandates that private citizens purchase policies (sin number one), and provides federal funding to subsidize such purchases (sin number two).

That’s a hard philosophy to argue for, though. It sounds terrible. It makes it sound like rich people should get better health care than poor people should. It makes it sound, in fact, like the lives of rich folks are more valuable than the lives of poor people. I think the conservative stance on health care is actually a principled one. But it’s based on bad theory, and on bad research.

The fact is that government-provided health care programs–specifically Medicare and Medicaid–are more efficient and effective and cost-effective than the care private insurers provide. Medicare is so efficient, in fact, that doctors don’t much like it. It doesn’t compensate them all that generously.

As to the philosophical point; is health care a right? Do all Americans have a right to affordable, effective health care? Should every American citizen have government provided-or-mandated health insurance? The answer to that question is ‘sure, probably.’ Health care is a right if sufficient numbers of citizens believe it to be a right. Besides, if we have a right to ‘life, liberty and the pursuit of happiness,’ that would seem to include a right to see a doctor without being bankrupted. The Framers wouldn’t have agreed, of course, because their health care sucked. The idea that going to a doctor was likely to make a sick person better is a reasonably recent one. But yes, health care is a right. How do I know that? Polling data says so. If 60% of Americans think health care is a right, then it’s a right.

Conservatism is on the wrong side of history on this question, which is hardly surprising, because conservatism is generally opposed to change. I mean, the most fundamental difference between liberalism and conservatism would seem to be ‘should things change, or should they not change.’ So, as change happens, conservatives tend, at least initially, to oppose it.

The other hallmark of conservatism is a commitment to free markets, a commitment which, of course, I share. I don’t want the government to regulate the prices of cell phones, or DVRs. I want the market to do that. But providing some commodities and services is generally beyond the capacities of markets. Roads should be built by the government, as should electric grids and sewage systems. And health care fits in that category. Health care is a service that is uniquely unresponsive to market ideology.

That’s why one consistent conservative answer to health care includes the expansion of health savings accounts. They’re not that terrible an idea. They’re also no panacea. You’d be able to put some of your money in a savings account, tax free, which you could then use to defray health care expenses. See, that way you would be incentivized to shop around, to ask several hospitals to quote you their best price for that MRI, for example.

Except very few people are ever going to do that. The relevant economic principle is ‘asymmetry of information.’ Doctors know more about our health than we do. If my doctor says ‘you need an MRI,’ I’m going to get one. Even if I ask for a second opinion, I’m not really reducing the asymmetry of relevant knowledge. i[‘m just seeing a second person who knows more about it than I do. That’s why insurance companies pay a lot of money to medical experts who determine if a proposed course of treatment is likely enough to work for it to be covered. And so does Medicare.

Does this reduce freedom? Yeah, some. We’re put our family’s health in the hands of these people, these doctor folks. It’s frustrating, and yes, we should (and do) inform ourselves, and research, and talk to people, and do whatever we can to take control of our own health. I agree with every effort to inform ourselves. But when the doc says ‘get an MRI,’ I’m getting one.

So what we’re currently seeing is conservatives trying to provide universal health care when they don’t believe in any part of it. Of course they look bad. Of course the results are bad. Barack Obama tried the most conservative, most market-oriented approach to increasing access to health care he could possible manage. The result is the ACA, and it’s not great. And all of its problems, all of them, stem from the fact that it’s a conservative, market-oriented approach to health care. We can and must do better. All Americans have a right to affordable health care. Time for us to do better.


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