Let’s pretend we had a Republican president who had carefully studied health care and a GOP whose Tea Party wasn’t the kind the Mad Hatter would throw. (I said we’re pretending.) What conservative, market-oriented, topflight health system might they pitch to the nation?
Certainly not the abortion of a bill the House passed last week. The American Health Care Act strips coverage from millions of struggling Americans. It would let states flee not only from Obamacare’s mandatory coverage of minimum, essential benefits but its requirement to cover preexisting conditions as well. States could herd sick people into high-risk pools, which would be underfunded, if the real-world experience that conservatives used to prize is any guide.
The real world offers another lesson. There are nations that have universal health care, with citizens contributing to their medical bills and the private sector playing a big role. (Obamacare, by preserving private insurance, is fundamentally a conservative program.) Obamacare phobics have exaggerated last year’s premium increases as the program’s death — the Congressional Budget Office expects prices to stabilize over time -- but our priciest-in-the-world medicine still demands reasonable ways to control costs.
Our make-believe GOP would learn from these other countries, jettison the nuttier principles of its loonies and suggest tweaks to Obamacare, which has brought us record-low numbers of uninsured.
For starters, nations with private-sector health mechanisms understand that government regulation and subsidies aren’t job and freedom killers, but rather essential tools to smooth the marketplace’s rough edges. Germany and Switzerland require all citizens to have coverage from competing private insurance plans, with government subsidizing the care through taxes. Both countries have conservative street cred: Germany invented compulsory insurance in the 1880s to neuter socialism’s appeal; Swiss voters in 2014 rejected single-payer health care.
Singapore mandates that everyone pay into a health savings account, via a payroll tax, for routine expenses. And every Singaporean is automatically enrolled in MediShield, the government-run insurance plan for big-ticket care. Singaporeans must take the initiative if they want to opt out of the latter.
American right-wingers loathe Obamacare’s individual mandate, but these other nations have done the math: Minus a mandate, only sick people buy insurance, and since they’re the costliest to treat, premiums soar, as states discovered when they tried high-risk pools. The mandate is hardly a jackboot on the neck of our freedom. Like laws mandating we stop at red lights or have car insurance, it’s a reasonable restraint on unfettered choice, necessary to procure a public good.
Our pretend GOP likewise would keep Obamacare’s essential health benefits. The German, Swiss and Singaporean governments all regulate the benefits insurers must offer. Critics of these essential benefits harp on things like maternity care, asking why Americans who don’t need it should pay for it. The answer is partly about the conservative virtue of personal responsibility. Childbearing-age women shouldn’t shoulder the costs of pregnancy alone, since “no baby ever has been born without a man being involved somehow,” as a Los Angeles Times writer noted. The writer added another rationale: Before Obamacare, when maternity benefits were a boutique option in insurance, the cost of having a baby was often unaffordable.
Having accepted regulated, subsidized medical care, reality-based Republicans could borrow other ideas from abroad. For example, conservatives complain that Americans use health insurance for even routine medical bills, insulating them from price consciousness. (“Nobody taps auto insurance to pay for tuneups or new tires,” The Boston Globe’s Jeff Jacoby observed.) Well, Singapore’s mandatory health savings accounts, Ezra Klein writes for Vox, are “unusually good at applying market forces to routine health expenses.” Klein is dubious Singapore's system could work here. But moderate Republican Sen. Susan Collins, walking proof that a sane GOP is possible, has proposed letting states keep Obamacare or else offer an alternative, including publicly funded health savings accounts.
Other overseas cost controls are more radical. Insurers in Germany and Switzerland are nonprofit. Switzerland has no employer-provided coverage. Doctors in those countries (and just about everywhere else) make less than their American counterparts, but crucially, they pay less for their medical education.
Having accepted regulated, subsidized medical care, reality-based Republicans could borrow other ideas from abroad.
Could any of these features be grafted onto American health care, and would they retard cost increases?
Unlike the House Obamacare replacement, these more radical ideas are at least sane and worth studying. Since we need to expand health coverage to reach the millions of Americans who are still uninsured, containing the cost of that expansion is vital.
But politics is politics. Klein writes that the lesson of Singapore is that "unusual fusions of conservative and liberal ideas in health care really are possible," but who says our conservatives and liberals want fusion? On the left, Democratic politicians face an activist base showing little hint of compromise on its single payer theology.
As for the Republicans’ House Freedom Caucus, which is so far to the right that it orbits Pluto, it agreed to the Obamacare replacement because the proposed bill dynamites the whole notion of universal coverage. It might take that wreckage (assuming the Senate agrees to the House's monstrosity, a big assumption) to make Trump voters realize lawmakers aren’t watching their backs, and demand that the GOP ingest some reality.