Universal Coverage: Too Politically Expensive

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.

I am generally all for pragmatism (e.g. I think that the very first thing the Republicans should have done on January 21, 2001 was to raise the minimum wage – in small annual increments for the next 30 years or so), but on this particular issue I want the GOP to fight to the death. I believe that Republicans should adamantly oppose the idea of universal coverage for constitutional, economic and political reasons.

To begin with, I’m not even sure what universal coverage really means, since the hospitals already are obligated to provide life-saving treatment regardless of the ability to pay and there are Medicare, Medicaid and numerous other federal, state and local programs providing healthcare either for free or at reduced sliding scale rates. Now, let me elaborate on my three reasons.

(1) It is not a proper function of federal government to provide universal health coverage. Once we surrender on this principle, how can we argue against universal nutritional coverage, universal housing coverage etc.? We really should not redefine the relationship between free citizens and the state in that way. There’s also a huge privacy issue here – the government may end up with medical records of all citizens (and besides endless possibilities for abuse – just think of prosecutors trying to stuff the jury with people awaiting approval for expensive experimental treatments – we know that the government has the habit of allowing sensitive information to be compromised, e.g. through losing a laptop). Then there are potential tangential attacks on liberty. Once we have universal coverage, its Democratic proponents will desperately want to demonstrate that the concept works, namely that the quality is good and the costs are under control. One of the potential metrics of quality is average life expectancy – and in fact the Dems are now making a big point of that parameter being slightly higher in many European countries with socialized healthcare. But once we have universal coverage, there will be huge pressure to demonstrate a jump in average life expectancy. And the dirty little truth is that in advanced post-industrial societies (relatively minor) variations in that parameter have a lot more to do with genetics, habits, crime, accidents etc. than with the healthcare system. So the federal government will try to go for those factors, and almost everywhere it will be at the expense of liberty.

E.g. the Dems have been relatively silent about guns in the last several years (in fact this is probably the only culture war in which Republicans are NOT badly losing), and considering that Obama’s Electoral College landslide was largely thanks to his spectacular success in the South and West, so far he has little incentive to go after those voters’ guns. However, the fact that whenever a young gang member dies at an age half a century below his theoretical life expectancy, the average life expectancy for all of us takes a big hit, may provide new incentives for the Dems to end the truce on guns. Also, people who survive gunshot wounds incur a lot of healthcare costs, and that’s yet another incentive to impose further restrictions on guns as well as further costs on gun owners (plus, it will be politically easier, once it can be claimed that gun owners impose extra costs on taxpayers).

There will probably be a lot of attempts to impose new restrictions and/or costs in other areas – smoking, skydiving, rock climbing, motorcycles, helmets, speed limits, allowed blood alcohol levels while driving, child seats, the minimal age for sitting in the front seat (since there’s nothing worse for average life expectancy than children dying in accidents), the minimal age for driving, swimming pools and beaches (especially when children are concerned) etc. etc. etc.

(2) The costs would be prohibitive. And we would open a can of worms. If we were to provide universal nutritional coverage, at least there’s an objective and clear definition of the amount of necessary coverage – enough calories to maintain body weight in the normal range. Universal education is trickier, but at least we still can come up with some common definition, e.g. 12 years of schooling and with a relatively broad consensus on what should be taught – furthermore, there’s generally no need to reconsider those definitions often, since there are not a lot of ongoing developments in the field of education. However universal health coverage would have to define what exactly is covered, and those definitions would have to be revised all the time, since we are in the midst of a medical revolution (and in fact it is crucial for medical progress to have multiple concurrent approaches to treatment, allowing for effectiveness comparisons, rather than just one centralized set of guidelines). Besides all other multiple implications, we should think really hard about creating an ongoing conflict of interest for the government, whereas on the one hand the government (FDA) approves new treatments and on the other hand it pays – or not! – for them (thus constantly putting the government in the awkward position of approving a new effective but very expensive treatment and then immediately refusing to cover it).

(3) I just don’t see what’s in it for Republicans politically. Universal health coverage will just expand the Democratic constituency. Yes, there’s a price for opposing it, but people like free stuff in general, and the GOP is supposed to be the party less enthusiastic about giving stuff away – and willing to pay the political price (anyway, trying to outbid the Dems on socialism is a losing proposition). Accepting universal coverage in principle will not get Republicans off the hook at all. Merely, instead of standing on an easy to understand constitutional and fiscal principle, they will find themselves opposing the Dems on myriad proposals to improve the coverage here or there and to start covering this or that treatment. In other words, rather than looking as principled heartless bastards they will look as unprincipled heartless bastards who have nothing against “free” healthcare in principle but just don’t want to pay for specific treatments for specific people (and yes, those people will be paraded on TV, juxtaposed with information about government contracts going to big Republican donors).

To read other contributions to this symposium, click here.