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How About Health-Care Reform for Realists?

Paul Ryan’s plan has all the sustainability of one designed by a right-wing Robespierre.

As a Canadian living in America, I find the intensely ideological nature of the U.S. health-care reform fiasco odd. Whether you are a free-market libertarian or a democratic socialist, these sorts of abstract commitments are only weakly correlated with the reform proposals on the table. In reality, the health-care debate in the United States is between technocratic reform A and technocratic reform B, with every feasible option tainted by varying degrees of profit motive and government force.

A businessman like Donald Trump is used to resolving conflicts over competing interests. When a real estate deal seems like it’s about to fall through, he simply raises the offer, buys off the holdouts, and gets to building. Values are secondary. As the punch line to the famously crude joke goes, “We’ve already established what kind of person you are. Now we’re just haggling over the price.”

Some hoped Donald Trump’s transactional style would help health-care reform rise above the fray, and back into the realm of concrete interests. But he ceded the reins to Paul Ryan and the Republican Study Committee, and the only compromises taking place are internal to the GOP establishment, and along gradations of ideological purity. This ensures that any health-care reform that passes Congress will once again be along precarious party lines.

Take their proposal to cap, block grant, and attach work requirements to Medicaid. As an effusive Paul Ryan recently shared at the National Review Institute’s Ideas Summit, it’s a plan he has pined for since the days he drank beer from a keg. But rarely does youthful idealism make for sound public policy. Even Robert Rector, the principal architect of the 1996 welfare reform, has come out warning that work requirements on access to medical care is an ideological step too far.

Ross Douthat at the New York Times was on to something when he observed that, on health-care matters, Republicans are guided too much by Milton Friedman, and not enough by Edmund Burke. Of course, Ryan’s effort to rationally construct a new health-care system from the basement under Congress might just work if liberal Democrats weren’t so likely to retake control in four years, and reverse all his reversals. Social-choice scholars have long understood the chaotic nature of narrow majority rule, and we’re seeing it play out here. Without letting the bill evolve in a way that satisfies more transpartisan interests, Ryan’s plan has all the sustainability of one designed by a right-wing Robespierre.

Conflicts framed in terms of primary values are simply less likely to find a stable equilibrium than ones framed in terms of tradable interests. If only the Israeli-Palestinian conflict were a matter of allocating territory, and not, as is actually the case, a dispute saturated by symbolism and identity. American politics has now entered such a sorry state that whether tax credits are adjusted by age or income is an object of comparable moral censure. This has to change.

Influential conservatives from Douthat to Christopher Ruddy ought to be commended for their recent dissent from party line. Ruddy, as CEO of Newsmax, took a particular risk last week when he argued that Trump should retake the initiative on health-care reform through the formation of a new bipartisan committee, and by advocating an “upgraded Medicaid system to become the country’s blanket insurer for the uninsured.” Conservatives for single-payer?

Douthat has argued something similar, if only by way of a prediction. He sees the current reform trajectory as stumbling towards a slightly less dysfunctional private market buttressed by a single-payer option he calls “Medicaid for most.” He would of course prefer the right’s vision of “getting to Singapore” (i.e., low-cost catastrophic coverage with forced health-saving accounts), but seems to recognize that it is at least as foolhardy as Bernie Sanders’s vision of “getting to Denmark” (to borrow a phrase).

If Ryan succeeds in sending Medicaid to the states and fixing its growth rate, the next wave of Democrats in power will see fit to expand and strengthen the program with some simple national standards for access and eligibility. At that point the U.S. health-care system will finally begin to feel familiar. That, after all, is approximately the Canadian system, although with a more developed private-sector tier.

Such a system, of course, is nobody’s ideal. But in the end, that may be the very reason it sticks.

Samuel Hammond is the poverty and welfare policy analyst for the Niskanen Center.



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