Blog & Reviews

Repeal and piecemeal is not a conservative approach to health system reform

Apr 23, 2017 | Blog | 0 comments

The National Review has published an opinion piece by Dan Mclaughlin which argues that Congress should repeal Obamacare all at once and then work over time to improve our health system.  His arguments arise out of his understanding of the meaning of conservatism.  As a conservative myself, I admire many of his principles, but differ with him as he applies them to health system reform.  Here are selected sections of his op-ed piece followed by my response in parentheses.

“The essential element of conservatism, more than any fixed principle or ideology, is experience. Conservatives believe in democracy, free markets, federalism, tradition, and the rule of written law for the same basic reason: These are all ways to bring the practical experience of the largest possible number of people to bear on the making of important decisions, rather than leave big decisions in the hands of a few unaccountable “experts.” And one of the important ways to demonstrate a decent respect for all these values is to take the world as it is – not as we might like it to be – and show some modesty about what we can accomplish in changing it, especially by the action of big, complicated government programs. Modesty means recognizing that nobody in Washington is smart enough to design a better health-insurance system on his own. The best system is one that is relatively simple, doesn’t try to do everything at once, and leaves the largest possible amount of power in the hands of individual consumers, and the power of experimentation in the hands of all 50 states. A system that is designed to solve all today’s problems for all time — even if it succeeded — would cast in stone an inability to respond to tomorrow’s problems until they reach crisis proportions.”

(I agree that we should all value human experience above any ideology.  Experience with modern health care is a relatively new phenomenon-it has been just over a century since clinical science developed to the point that visiting a doctor was more likely to help than to hurt the patient.  Of course, experience with caring for the sick and injured has a much longer history and is embedded in human religion.  It is inherently conservative to believe that we all have a duty to see to the needs of the sick and injured.  Experience with free markets pre-dates the advent of clinical science, too.  However, conservatives have tended to mix the ideologies of markets and medicine and talk as if we all should venerate health insurance and other business models on a par with the ancient religious experience with tending to the ill and injured.   In fact, no health policy that relies upon health insurance and other for profit business models will be simple, empower patients, and leave experimentation in the hands of 50 states.   The health policy that will do that is state-based single payer health system reform.)

“But the bad news for conservatives is the flip side: A lot of people, many of them now Republican voters, depend on government subsidies (via Medicaid or otherwise) to cover their health insurance. Republican deregulatory policies can reduce some of the costs of insurance, by eliminating barriers to interstate competition, reducing tort liabilities, converting “essential benefits” mandates into disclosure requirements, etc. But they can’t, any time soon, solve the basic problem, which is pervasive in education and health-care debates these days: The costs have spiraled so far out of the reach of ordinary middle-income people that they’ve despaired of paying for them from their own earnings. And even if they could, it would take time to resolve the political reality of finding new insurance for the people who are currently on the Obamacare dole, who will need to be grandfathered to allow them to stay on the current system for some time.”

(All people in the US depend upon government subsidies of health care, especially those with employment based health benefits.  The federal government began propping up the private health insurance business model 75 years ago after WWII through massive tax credits.  No one, not even the wealthiest Americans, can afford to provide for state of the art clinical care for themselves.  It is simply too expensive to have every possible clinical care service prepped constantly for the time that one person or their family might need it.  We depend upon public funding for health care, all of us.  Any attempt to deregulate health insurance is furtherance of this propping up, favoring the few over the needs of the many.  No one needs health insurance, which is the most useless, wasteful way ever invented to pay for health care.  There is ample experience world wide to document this.  Conservatives should therefore plan to get rid of the health insurance business model and do so by repealing Obamacare, the most recent government prop supporting it.)

“By contrast, a repeal-first strategy would change the game and might even let Congress break the partisan gridlock on health care. The Byrd Rule means that Democrats have the power, if they stand united, to make it impossible to pass a single, comprehensive Republican health-care proposal. But it doesn’t give the Democrats the power to prevent Republicans from repealing and defunding so much of Obamacare that it is no longer a viable option. If Republicans do that, they can bring a significant number of Democrats to the table. Once the current system has been scrapped, nobody who wants the government to pay for health care or regulate health insurance could afford to stay on the sidelines. By burning the ships behind them, Ryan, Trump, and Mitch McConnell could — paradoxically — create more incentives for bipartisan de-escalation and compromise.”

(The pathway to bipartisan health system reform is to combine the conservative interest in state-based solutions with the democrats desire to find a way to include everyone–single payer.  I agree that having democrats play defense around Obamacare is a big political problem–in many ways Obamacare is the problem.  Repeal it and offer not piecemeal replacement, but state based single payer replacement.  This would have the advantage of being fiscally conservative with overall savings closing in on $1 trillion per year.)

“A large, complex, federal-driven health-insurance solution is an incredibly ambitious public-policy initiative, and you don’t pass that through Congress (without extensive political blowback) unless you sell it to the voters. But if any Republican is up to that job, it’s not Trump.”

(Trump is on record supporting single payer health system reform.  He is the ideal president to sign the bipartisan bill to make this happen.)