Tens of millions of Americans lack health insurance. Extending coverage to them has been a core goal of health reform proposals since the 1960s. President Richard Nixon offered a universal health plan in his first administration, but since then Republicans have hesitated to commit the nation to so costly an undertaking. Is it time to rethink? Should Republicans accept universal coverage as a goal? We posed this question to NewMajority’s contributors.
The question before the House is whether or not the time has come for conservatives to endorse the goal of universal health insurance. The answer at the present time must be no, and it must be no for parochial reasons. Given the make-up of the Congress and the occupant of the White House any such program would, if passed, be far more statist , expensive, and hostile to innovation than any such program formed even two or four years from now. If a body of conservatives adopted universal health insurance as a goal right now it would split the opposition to Obamacare , which has none of the hallmarks of a conservative social insurance program, and allow for the co-option of the opposition just as they are registering success. Obamacare as it now stands is an issue that divides the Democrats and unites Republicans. No proposal that changes this formula ought to be suggested by the Right. The projection of $9 trillion in deficits also highlights the reality that no funds for such a program, however devised, are available. Such a project would divert, rather than aid conservative efforts to bring the deficit into a manageable range without further damaging the economy.
This is a tactical answer to a larger question however. If a time like the mid-60’s, the mid-80’s, the mid-90’s, or the mid-2000’s came again and economic growth was restored with deficits as a measure of GDP dropping, and Republicans had at least partial control of one branch, could a conservative program properly include universal health coverage? The answer, though closer, must still be no. It is a much closer question because of the permanent advantage Democrats and liberals have had on this question in politics, the huge advantages in placing the young, healthy people now uninsured into the insurance pool, and the fact that society writ large pays the healthcare costs of even the uninsured.
Any proposal that requires an individual to have health insurance has three negative consequences for conservatives. First, it violates the principle that the individual and not the government controls his own decisions in a vital area of personal behavior. Second, it vastly increases the costs of health insurance. Third, it raises the bar for the bidding war of what government spends on healthcare . The first principle is that if someone does not want health insurance he ought not have to purchase it. The rejoinder has always been that if he is catastrophically injured someone will. What this overlooks is that millions upon millions of uninsured are never so catastrophically injured. They either pay for their own check-ups and the like, or they forego them. In either case they cost the public zero. By absenting themselves from the insurance market they also lower the demand for the product and thus price.
This dovetails with the second point. Healthcare is expensive. The more we mandate requirements the more it will cost. Much of that cost will be on government which can ill afford it. Medicare and Medicaid are breaking the government. If all they covered was what they covered in 1965 that might not be the case. Inexorably they expanded. This leads to the last point. Once universal care is the goal the fastest and easiest way to do so is a government mandate. The Democrats will always outbid Republicans on the form of that mandate and what is included.
We have only to look at Europe, or North of the Border, or to Medicare and Medicaid, to see what the assumption that government will require and provide healthcare to all citizens does to conservative parties. They become unconservative . Republicans increase Medicaid spending and ask to be rewarded by the public for it. The Tories trip all over themselves stating how much they will increase funding for the National Health Service. A conservatism based on Bismarkian assumptions can propose universal coverage, one based on Burkean considerations cannot.
So what does this leave? It leaves conservatives with incremental improvements. There is no “health crisis.” As Obamacare has cratered we have seen that most Americans are satisfied with their healthcare. The population that is not can be whittled down by sensible conservative reforms, many of which have already been proposed but languish because Democrats do not want market solutions, or any solution that reduces the problem but either 1) does not eliminate it entirely or 2) does not increase state control of healthcare decisions. This allows conservatives an approach that has served us well in the past; point out that the Democrats are making the best the enemy of the good, and provide reasonable, cost effective improvements without upsetting the entire apple cart of a healthcare system that is, with all its faults, delivering high quality service to most of the people, most of the time.
To read other contributions to this symposium, click here.