The American Health Care Act – a bill engineered to transform the healthcare of the poor into precious metal for the rich – has departed. Let us hope it stays in its admittedly shallow grave.
Its implosion on Friday – attributable to some combination of the intransigence of the House hard right, an extraordinary lack of popular support, and an impressive show of grassroots antagonism – will prove to be a pivotal moment in healthcare history, for at least two reasons.
First, it is tantamount to a societal rejection of the conservative healthcare ethos. Second, it may very well open the door to more progressive, fundamental healthcare change in the years to come.
Would-be Trumpcare had three main pillars: continue the Affordable Care Act’s (ACA) subsidization of private health plans (though recalibrated along highly regressive lines), shrink Medicaid by about 25% over a decade, and provide lavish tax breaks to the rich.
It was thus the evil cousin of Obamacare: it would have benefited the well-off at the expense of the working class and sick, it is true, yet it would also have conserved Obamacare’s overall organization, and left many of its insurance regulations intact.
This last fact played a major role in the bill’s fate, for it alienated hard-right true believers in the “House Freedom Caucus”. Conservatives contended that it would only be by eliminating Obamacare’s various insurance regulations – including the one that requires that plans cover “essential health benefits“ like hospitalizations, maternity care and medicines – that premiums would fall.
They are not entirely wrong on this point: skimpier plans are cheaper. Likewise, we could lower rent if landlords weren’t expected to provide heat, running water and a low risk of structural collapse.
And ideologically, for true believers in the conservative ideal of healthcare freedom, governments shouldn’t mandate that plans cover particular benefits any more than they should require that all pizzas be sold with some arbitrary assortment of toppings (which would admittedly not be to everyone’s tastes).
Why, for instance, should I be forced to pay for coverage of prenatal care, if I have no uterus? And no emphysema coverage for me, thank you very much! – as a pulmonologist I’m wise enough to have other vices than cigarettes. Of course, even putting aside old-fashioned notions like solidarity and basic decency, as policy such sentiments are puerile nonsense.
We cannot know what medical problems we will encounter: a system wherein we all select coverage tailored to our unique gonads, bad habits or unlucky genes would be as dysfunctional as it was cruel.
Yet to the dismay of many on the right, the Trumpcare bill did little, at least initially, to let a thousand health insurance plans bloom. These hard-right House Republicans were unimpressed, seeing the bill as little more than Obamacare reincarnate.
In the 18 days between the introduction of his bill and its death, Speaker of the House Paul Ryan strove to mollify them: he offered modifications including a Victorian-era themed provision to encourage states to impose work requirements on Medicaid participants, an option for states to more radically degrade Medicaid through “block granting”, and – at the eleventh hour – a provision to shred Obamacare’s “essential health benefits” requirements.
All was to no avail. For Trumpcare had almost no popular support – a widely cited poll found that pathetically few Americans (a mere 17%) liked what they heard – and each slide to the right risked shedding more support from so-called “moderates”, who probably mostly feared for their own necks (electorally speaking) by lining up behind such a widely detested bill (which could have been a factor among hard-right lawmakers as well). With an excess of defectors on both sides, Ryan and Trump were forced to declare a humiliating defeat.
Trumpcare, it is clear, belongs in the dustbin of history. But with it should go the pernicious principle at the heart of conservative healthcare policy. The right promises “choice”, which is intrinsically appealing, for we all want choice in healthcare: the right to choose our doctor, and to receive care that comports to our unique needs and beliefs.
Yet what the right – and, for that matter, the center – promise is the mostly empty choice of insurance coverage. But coverage choice dictated by one’s wallet is frequently no choice at all. More importantly, the greatest choice in care is found in a universal system with a single tier of comprehensive coverage.
And so, it may be the second legacy of Trumpcare’s defeat – the opening of a window for progressive healthcare change – that will prove even more consequential. Trump lied – he was never going to deliver “insurance for everybody”, as he promised in an interview with the Washington Post – but that’s what people want.
The only feasible path to that goal – the one that would produce the savings needed to cover the new costs – remains a universal system with single-payer financing. The next move for progressives is therefore a no-brainer, both politically and morally: coalesce behind single-payer as the healthcare vision of tomorrow.
