In our ideologically scrambled age, it's getting very hard to tell who's who.
Political conservatives have been opposed to "socialized" medicine pretty much forever. Republicans who agreed with this philosophically paid a heavy political price as Democrats rolled out the "Mediscare" tactic every election season.
But how are we to make sense of the cross currents on the right regarding the American Health Care Act? The groups often associated with the "hard right," such as the House Freedom Caucus, the Club for Growth, and Heritage Action, have panned the bill as "Obamacare 2.0." Rep. Mark Sanford noted, "From a conservative's perspective, there are a number of things that need further refinement. This notion of a refundable tax credit is a big deal; Medicaid expansion is a big deal; the Cadillac tax is a big deal." Rep. Jim Jordan offered that this bill is "Obamacare in a different form. That is not what we promised the American people that we're going to do."
Cynics might note that some Republicans who publicly oppose the AHCA for not going far enough in a rightward direction are secretly hoping that the bill fails because Obamacare is actually reasonably popular with their voters.
The president, who is not a conservative, at first seemed to back the AHCA. "Our wonderful new Healthcare Bill is now out for review and negotiation. Obamacare is a complete and total disaster — is imploding fast!" he tweeted.
But the Trumpian populist media, such as Breitbart and Newsmax, may be hostile to the AHCA for other reasons. Fox News commentator Laura Ingraham lamented that the bill lacks the "Trumpiest" features of health care reform, and Breitbart — never subtle — is calling the bill "RyanCare." What are the "Trumpy" features of health reform? Trump's campaign promise of a replacement for Obamacare that would cover everyone and cost less was cotton candy.
The AHCA can be understood as that most reviled of creatures in Washington, D.C. — a compromise. It begins with the understanding that due to the extreme partisanship of the nation and the Senate filibuster rule, Republicans must devise a bill that can pass the Senate with 51 votes though "reconciliation." Only matters touching directly on budgets and deficits can be included. That's why the AHCA leaves many of the Obamacare regulations in place.
As a conservative, I would love a bill that actually created a free market in health care. We haven't had one since before World War II when Congress made employer-provided (but not individually purchased) coverage tax deductible, and particularly since 1965 when Medicare and Medicaid were enacted. Congress further distorted the market in 1986 by requiring hospital emergency rooms to treat everyone regardless of ability to pay. Those costs were passed on in the form of higher medical bills for all.
The third-party payer problem and government distortion of prices has resulted in medical inflation running twice the level of the Consumer Price Index for five decades. Everything government has done to make health care "affordable" has made it more expensive. Obamacare doubled down on everything that was wrong, basically outlawing the whole idea of medical insurance — i.e., a plan you buy to guard against a health disaster like an accident or cancer — in favor of prepaid medical services that are funded (well, in theory) by forcing healthy people to purchase plans that are "ACA compliant."
The whole system would make Rube Goldberg blush. And as much as we might wish for a sword to cut the Gordian knot, the only politically possible options seem to be slow turns away from the single-payer precipice, perhaps in stages.
The AHCA takes some steps in that direction, particularly with the reform of Medicaid, the move toward health savings accounts, the repeal of $1 trillion in taxes and the revoking of the medical device tax. But compared with current law, the bill is hard on the working poor, and too generous to those at the upper end of the income scale. As health policy guru Avik Roy has objected, the subsidies the AHCA offers to those making between $75,000 and $150,000 are actually more generous than Obamacare's subsidies. For the working poor, by contrast, who make too much to qualify for Medicaid, the subsidies would be much smaller and probably inadequate.
The rush to pass the AHCA — leadership had planned for a vote by next month — is based on political momentum, and that's understandable. Political capital is a highly perishable commodity. But Republicans would be well-advised to slow down and improve the bill. They should not follow the Hollywood script doctor's demand: "I don't want it good; I want it Tuesday."