There is an old saying, that if Democrats were to propose burning down the White House Republicans would counter with a plan that would burn it down “better” for half the price, though it would take half again as long to accomplish. I have been reminded of this saying repeatedly over the past several weeks as various “mainstream” Republicans, including Utah Senator Orrin Hatch, journalist William Kristol, and former Bush adviser James Pinkerton, among others, have floated “alternatives” to the Affordable Care Act. As so often in the past, “mainstream” Republicans, fearing that a liberal program might genuinely fail, are rushing to fix it by replacing it with a more cautious version of the same program.
The details frankly are not worth pursuing. Suffice it to say that “mainstream” Republicans prefer to manipulate the tax code rather than make their subsidies in the open. But Republican “alternatives” all rest on the mistaken notion that there is some set of key needs they can address with a program that is less expensive, intrusive, and unwieldy than the Affordable Care Act. I say “mistaken” because all these proposals by their very nature are formed in the logic of social democracy. The people have a need. It is not being met as well as we would like. So the government must devise a program to better meet that need.
It should be self-evident to everyone outside the “mainstream” of Republicanism that such logic inevitably will produce, on an ad-hoc basis, the very government-run system they claim to be avoiding. Like the Affordable Care Act itself, “mainstream” systems will have significant “gaps” and “imperfections” created by the failure to impose a seamless administrative structure. The federal government will, of course, be happy to remedy such problems through additional, more systemic, reforms. The result inevitably will be a nightmare, but it will be a government-run nightmare, and the government will be in charge of reforming it forever after.
Sadly, this point—and people’s control of their own healthcare decisions—was lost when it became established dogma that “insurance” must be universal. Insurance is merely a means of pooling risks of calamity. I buy life insurance to provide support for my family in case of my unexpected demise. The insurance company pools money from people like me, invests it, and pays out portions when needed—keeping part of the whole for administrative overhead and profit. The further we get from the one-time calamity scenario, the higher the administrative overhead as we move from insurance toward “provision of services.” There may be a continuum between life insurance and comprehensive healthcare, but it is a very steep continuum, and its slope is quite slippery.
This administration’s attempts to bully and bamboozle healthy young adults into buying into the Affordable Care Act is just more proof that the system is less about insurance than it is about finding a way to subsidize a government program to provide healthcare services. So why do mainstream (they would prefer, of course, to be termed “responsible”) Republicans want to have a somewhat smaller and more efficient version of the same thing? Because they are afraid of looking like they do not care about poor people. And, of course, today the only way to appear to care about poor people is to offer them a government plan.
America was not always this way. There was a time when caring for those less fortunate than oneself meant dipping into one’s own pocket, instead of pretending government programs do not get their funding by reaching into other people’s pockets. In fact, one of the central factors producing our current healthcare crisis has been the death of the true charitable hospital. Another factor, of course, has been our tax system’s crude incentives, which have pushed employers into the business of providing health benefits instead of leaving them to provide decent pay and leaving employees to purchase healthcare plans on the open market. And a number of factors have stopped almost all Americans from banding together with other people (as Catholics, or Jews, or machinists, or members of various other groups, as once was the norm) to purchase healthcare services.
The assumption today is, of course, that any return to such a system of free markets, freedom of association, and the freedom to provide charitable services (something our tax, insurance, and tort law currently renders essentially impossible) is not possible. One thing is for certain, it will never be possible so long as the Republican “mainstream” continues to think like a group of social democrats.
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