Over at The Resurgent, Senator Mike Lee (R-Utah) explains why he would not support the compromise health care plan, even with the (amended) amendment he and Cruz proposed. And I think that Lee is perfectly sincere in his argument, and I think that his argument shows why a lot of lefty critiques of Trumpcare just don’t quite work, but I’ll explain that after I try to be really, really fair to his argument.
Lee’s objection to ACA is that: “Millions of middle-class families are being forced to pay billions in higher health insurance premiums to help those with pre-existing conditions.” He calls it a “hidden tax,” since it’s “paid every month to insurance companies instead of to the government” and he maintains that hidden tax is: “one of the most crushing financial burdens middle-class families deal with today.”
Lee’s proposals is not, as many say, that people with pre-existing conditions and expensive medical costs would get thrown off insurance entirely. Instead, this plan would split insurees into two groups: people who already have high medical costs, and are bad risks for insurers, and people who have not yet developed expensive medical costs (whom Lee consistently identifies as “the middle class”–that’s an important point, since it implies that he thinks the middle class and people with serious medical costs are different groups). The people with high medical costs, Lee argues, shouldn’t be protected through price-fixing: “We don’t have to use price controls to force middle-class families to bear the brunt of the cost of helping those who need more medical care. We could just give those with pre-existing conditions more help to get the care they need.” So, insurers are “free” to charge whatever they want, and consumers are “free” to get insurance or not (hence the name “Consumer Freedom Amendment”), and this plan will not put the financial burden of healthcare of others on “middle-class families.”
There are a few points about Lee’s plan that are interesting. The first is that my social media has had a lot of criticisms of Trumpcare and this amendment, and none of them explained it correctly. The main criticism has been that this will throw large numbers of people with serious medical issues to the wolves–that millions will be unable to get insurance. The impression I had gotten from various articles was that Cruz, Lee, and others were cheerfully and knowingly ensuring that millions of people would lose access to their healthcare. And that isn’t quite right, and I think it’s important to get opposition arguments right (both because it’s more rhetorically effective, and because it’s more important for policy deliberation).
Jordan Weissman has a nice article at Slate that does an unusually good job of explaining the various proposals, especially Lee’s argument: “Lee doesn’t believe that healthy Americans should help pay for sick ones through their insurance premiums, and he doesn’t want to put his name on a bill that might—in theory, depending on regulatory decisions, maybe, one day—allow that to happen.”
So, what’s at stake for Lee (and many others) is the notion that paying for healthcare is paying for someone else–for a different group. The really tragic failure here is the failure to imagine an “us” that includes all Americans.
Lee’s argument is a little inconsistent on that point, though. He admits that the subsidies will be paid for in taxes, so the healthy will, in fact, still be paying for the unhealthy. Even if it’s done through tax breaks rather than subsidies, we all pay, since we will pay in the form of less infrastructure and lower funding of all public “goods.” While I do think I understand (but don’t agree with) the reasoning behind the insistence that people who don’t have jobs don’t “deserve” healthcare, I’m not sure I understand this theme that comes up a lot in current conservative talk about public goods–it’s as though they don’t understand that publicly-owned things aren’t owned by no one; they owned by everyone. And public goods aren’t given to them; they’re given to us.
The math on how healthcare expenses work out is not complicated. It might be worrisome ( e.g., how can we pay for an aging citizenry), but it isn’t really complicated: for ever person to who takes a dollar out, there must be someone who puts slightly more than a dollar in (so the insurance company can make some money, and let’s all start with the fact that they’re all doing pretty damn well). That dollar in/out might be direct (it’s a thing on your paystub, and you put it in) or it might be indirect–sales tax, user taxes, sin taxes, but (and this is important) if health care happens, someone pays for it.
A US Senator recently told this story. He was mowing his lawn, and a constituent came up to talk to him (because he is the kind of guy who sees every resident in his state as a constituent, unlike, say, Ted Cruz). That guy said he should be forced to pay for health care because he never got sick. “Oh really,” said the Senator. “You’ve never been to the ER?” “Oh, sure,” the constituent said, “but that’s free.”
That’s an important story–that you are not charged in the moment does not make a service free. Lee hasn’t learned that lesson. (And here I’ll make a generalization and say that I’ve yet to argue with a neoconservative who understands that point–you can see it in the twitterfluffle over Grover Norquist’s failure to explain taxes to his daughter.)
It doesn’t matter if someone (even a middle class person) has medical costs that are paid for by the state or by an insurance company. Ask not for whom the bell tolls. All costs in a nation will end up being shared by everyone in the nation; the only interesting question is whether that sharing is “fair,” and that’s the whole issue with someone like Lee. Fairness might mean “everyone gets the same treatment” or it might mean “people get what they deserve.” People who self-identify as “liberal” tend toward the former, and people who self-identify as “conservative” tend toward the latter–they think it is “unfair” for people like them (their ingroup) to pay, in any way, for people like them (their outgroups). It’s unfair because they believe “people like us” have worked hard for what we have, and they haven’t. And, so, what they want are policies that presume an absolute and easy distinction between good and bad people and that magically restrict the goods to good people.
I don’t think that’s practical, as I don’t think it’s possible for public policy to make such clear distinctions between good and bad people, and I certainly don’t think that Lee’s “middle class” versus “people with pre-existing conditions” distinction is sensible. But, it’s an attractive argument to a lot of people because it’s simple, satisfying, and has just enough punitive spice in it to be pleasing. And, as in all us v. them rhetoric, it’s flattering. If we’re going to try to argue against these sorts of policies, and I think we should, we need to do it while understanding what their argument is, and it’s more complicated (and attractive) than is being acknowledged in a lot of lefty rhetoric.