What the midterms mean for the future of health care.
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| © Rick Wood/Milwaukee Journal-Sentinel, via Associated Press
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By PAUL KRUGMAN, The New York Times
Let’s be honest: Despite his reputation as a maverick, John McCain spent most of his last decade being a very orthodox Republican, toeing the party line no matter how irresponsible it became. Think of the way he abandoned his onetime advocacy of action to limit climate change.
But he redeemed much of that record with one action: He cast the crucial vote against G.O.P. attempts to repeal the Affordable Care Act. That single “nay” saved health care for tens of millions of Americans, at least for a while.
But now McCain is gone, and with him, as far as we can tell, the only Republican in Congress with anything resembling a spine. As a result, if Republicans hold Congress in November, they will indeed repeal Obamacare. That’s not a guess: It’s an explicit promise, made by Vice President Mike Pence last week.
But what about the problems that sank the repeal effort in 2017? Surely Republicans have spent the past year rethinking their policy ideas, trying to come up with ways to undo the A.C.A. without inflicting enormous harm on ordinary Americans, especially those with pre-existing medical conditions. Right?
See, I made a joke.
Of course, Republicans haven’t rethought their ideas on health care (or, actually, anything else). Partly that’s because the modern G.O.P. doesn’t do policy analysis. Democrats have a network of think tanks and sympathetic independent experts who look hard at evidence, try to devise solutions to real problems and sometime affect actual legislative proposals. Republicans have nothing comparable; their tame “experts” are basically in the business of saying whatever their political masters want to hear.
In the case of health care, however, there’s an even deeper problem: The G.O.P. can’t come up with an alternative to the Affordable Care Act because no such alternative exists. In particular, if you want to preserve protection for people with pre-existing conditions — the health issue that matters most to voters, including half of Republicans — Obamacare is the most conservative policy that can do that. The only other options are things like Medicare for all that would involve moving significantly to the left, not the right.
Health economists have explained this point many times over the years; but as always, it’s difficult to get a man to understand something when his salary depends on his not understanding it. Still, let’s try one more time.
If you want private insurers to cover people with pre-existing conditions, you have to ban discrimination based on medical history. But that in itself isn’t enough, because if policies cost the same for everyone, those who sign up will be sicker than those who don’t, creating a bad risk pool and forcing high premiums. That was the case in New York, where premiums for individual policies were very high before the A.C.A. — and promptly fell by half when Obamacare went into effect.
For what Obamacare did was provide incentives to get healthy people to sign up, too. On one side there was a penalty for not having insurance (the individual mandate). On the other, there were subsidies designed to limit health expenses as a share of income. Republicans have tried to sabotage health care by doing away with the mandate, and have succeeded in driving premiums higher; but the system is still standing thanks to those subsidies.
The point, again, is that Obamacare is the most conservative option for covering pre-existing conditions, and if Republicans really cared about the scores of millions of Americans with such conditions, they would support and indeed try to strengthen the A.C.A.
Instead, they’re going to kill it if they hold on in two months. But covering pre-existing conditions is popular; therefore, they’re pretending that they’ll do that, while offering proposals that would, in fact, do no such thing.
Why do they imagine they can get away with such brazen fraud, because that’s what it is? Do they imagine that voters are stupid?
Well, yes. In recent rallies Donald Trump has been declaring that Democrats want to “raid Medicare to pay for socialism.”
But the more important target is the news media, many members of which still haven’t learned to cope with the pervasive bad faith of modern conservatism.
When someone like, say, Senator Dean Heller of Nevada co-sponsors a bill that purports to protect pre-existing conditions but actually doesn’t, what he hopes for are headlines that say “Heller Announces Plan to Protect Americans With Pre-existing Conditions,” with the key fact — that his bill wouldn’t do that at all — buried in the 17th paragraph.
Or better yet, from his point of view, that 17th paragraph would state only that “some Democrats” say his bill is a fraud, while Republicans disagree. Both sides, you know.
So if you’re an American who suffers from a pre-existing medical condition, or fear that you might develop such a condition in the future, you need to be clear about the reality: Republicans are coming for your health care. If they hold the line in November, health insurance at an affordable price — maybe at any price — will be gone in a matter of months.
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