Healthcare has been an issue that the GOP has not been able to grapple with going back to the debate over Medicare and Medicaid during LBJ’s Great Society program. At the time, the conservative AMA opposed Medicare, as did the conservative movement in general. Ronald Reagan famously declared in a speech that American liberty would end if we enacted Medicare.
The reality has been that Medicare is one of the most popular and successful government programs, and along with Social Security, ensures that the vast majority of elderly people in America do not spend their final years in destitution. Before 1960, the elderly had the highest poverty rate of any demographic, they now have the lowest.
The reason Medicare was necessary was based on three facts that made such a program inevitable. First was the rise of modern medicine. When the doctor was making house calls, there wasn’t really that much more that could be done in the hospital, other than surgery. But by the 1960’s, medicine was entering its golden age. Scores of new powerful antibiotics, advances in radiology, development of dialysis, organ transplantation, open heart surgery, chemotherapy, and a plethora of new medications were becoming available. The problem was that these new treatments were very expensive, much more than a simple house call and a penicillin shot. The second trend was that private insurance for the elderly had failed. It was simply not possible for insurance companies to charge the elderly the full cost of medical insurance because they were generally in poorer health and high users of medical services. The premiums would have been way too high for all but the richest, and the relatively healthy would avoid buying insurance leaving the pool even more costly and untenable. On the flip side, the elderly were no longer in the workforce, and so neither had the income to buy insurance or an employer to provide it. The third trend was the recognition that if we all wanted the best of modern medicine, we had to be able to pay the hospitals and doctors to care for the elderly that would inevitably show up in their emergency room with serious illnesses. If we didn’t the system could not afford to upgrade and make available these new services.
Medicare solved this problem by shifting the cost of medical care for the elderly onto all of society, with the promise that it would take care of todays workers when they retired. It also relieved families of the stress of paying for elderly relatives medical care. All workers would contribute through payroll taxes added on to the existing Social Security payroll tax.
In addition to Medicare, LBJ also got Medicaid through Congress, which provided insurance for the poor and disabled. Its eligibilty and benefits varied as it was a federal state partnership, with states in the South being very stingy, while more liberal states were more generous in terms of who qualified. A constant though was that all disabled people, pregnant women, and in the 1980’s those with HIV, automatically qualified. Medicaid underpaid hospitals and doctors compared with Medicare and private insurance, and many specialists did not take on Medicaid patients limiting access to these services. Even today, it is very difficult for a patient with Medicaid to get elective orthopedic surgery in California.
The GOP eventually made its peace with Medicare, especially as its voters aged into that demographic. This explains why W pushed through the Medicare drug benefit, the largest expansion of Medicare benefits since dialysis coverage was added in the 1970’s. But while they electorally no longer could oppose Medicare, they philosophically opposed healthcare still, with their lockstep nyet to Obamacare.
Why did the GOP take such a hardline stance? They remain deeply confused by the ethics and politics of healthcare. To conservatives, all goods and services should be distributed by the market, with those who can afford it getting what they can buy, and those who can’t are left out. This applies to most things like high end automobiles and beachfront property, but the GOP can’t see why health care is an exception.
The answer is in the Declaration of Independence. The Founders recognized the essential purpose of existence to have three parts, life, liberty, and the pursuit of happiness. And of the three, life comes first. Without that, the whole American project is pointless. To protect life is the primary purpose of government. As such, the government must do everything it can to protect the lives of its citizens, whether it be from external invasion, criminal violence, or lack of access to modern healthcare. Yet the GOP on some level thinks that people without insurance don’t deserve to live at the expense of society (as they shouted at the debate in 2012 to “let them die”).
While they philosophically do not accept that we have a responsibility to provide health care for all, they also do find Obamacare an attack on freedom. This line of assault, which formed the basis of the SCOTUS case that almost voided Obamacare in 2012, until apparently Roberts changed his mind and voted to uphold the ACA, rests on the odd notion that penalizing people who don’t buy insurance they can afford is a taking of their “freedom”. The “freedom” to be uninsured is not freedom. It is in fact the free-rider problem. If the GOP really saw this as a question of freedom (and I doubt a single one of the GOP staffers, politicians, and lawyers behind the suit were choosing to go without health insurance in the name of freedom) they would also be for the freedom of the healthcare industry to not treat people for free.
In the 1980’s there was a crisis of “patient dumping”, where private hospital emergency rooms were turning away patients without insurance, and ambulances would drive around trying to find a place to take sick patients. Often they would end up in overcrowded county hospital ER’s, the cost of which was being paid for by the public through taxes. In 1984 Reagan signed EMTALA, a law that forbade the practice. Under EMTALA, emergency rooms were required to evaluate all patients regardless of insurance, and they could not discharge anyone who wasn’t medically stable to leave. The result was that hospitals, and the doctors on call at those facilities, were now forced by law to provide care to emergently ill, even if they had no ability to pay. In short, doctors and hospitals were being asked to provide free care. As a doctor, I have provide over a million dollars of free care in my 20 year career due to the consequences of this law. Now don’t the private doctors and hospitals have a valid conservative claim that their freedom is impinged by EMTALA? What other industry is forced to provide services to those who can’t afford their product? My response to the GOP attack that the ACA is an assault on freedom is why then is EMTALA not a greater assault on freedom? If we want to live in the GOP fantasyland, then lets get rid of the ACA but also get rid of EMTALA and let people really die in the street in misery and pain. Are we really going to let some mother die from gallstones because she is too poor to have insurance? Or some child die from a skin infection because he skinned his knee?
The GOP knows that is not politically acceptable so they hide their “freedom” argument behind a lot of nonsense. But in addition to the moral imperative to provide healthcare for all, there is a great utilitarian argument to be made. Good prenatal care saves society vast amounts of money taking care of premature births and children with developmental problems. A healthy workforce is going to be more productive and innovative and capable of faster growth. Adequate preventive care can save society long term. I remember one patient I took care of, a middle age Latino immigrant who worked hard to provide for his family. He also had high blood pressure that he left untreated because of no insurance. I took care of him after he suffered a devastating stroke leaving him paralyzed on one side. Now instead of working, he would go on Medicaid at taxpayer expense, and his family would rely on TANF and food stamps. Proper care would have saved a lot of money and prevented a terrible tragedy for this family. I have seen too many cases of people suffering major harm from lack of insurance. I still remember 20 years ago I saw a five year old girl with a bad foot infection that the family had hoped would get better on its own, they could not afford a doctor or medicine, and when they finally realized it was very serious they brought her into emergency. By that point the infection was so bad, we had to amputate the foot. That case made me very angry at our asinine healthcare system, and at those who opposed its expansion to cover everyone. EMTALA allows people to get care in emergency rooms, but they can rack up huge hospital bills, and private hospitals are very aggressive about collections. The end result is tens of thousands of Americans forced into bankruptcy by medical bills.
The ACA has been a huge success. Despite 6 years of bleating about “repeal and replace” there is no replacement plan. The GOP has no healthcare policy, because what it does have is politically toxic. What they want is to repeal the ACA and replace it with the old system. But that system, with the right of insurance companies to turn you down for pre-existing conditions, and the lack of affordable insurance for the working poor and lower middle-class, meant that tens of millions lacked health care access, and tens of millions more were just a job loss away from joining them. Going back to that is politically impossible now, the ACA has gotten into the system too deeply. While GOP leaders talk about repeal still, their heart is just not in it anymore. The GOP base doesn’t hate the ACA, other than it gives benefits to brown and black people, but they are happy with many of its key elements. This can be seen clearly in how little Trump has to say about healthcare. His campaign is built on nativism and xenophobia, but he has no intent of dismantling the welfare state, including the ACA. The poor whites that support him depend on it.
It may take one more election for the GOP to come to terms with the ACA and the idea that all deserve health care as a basic human right. They implicitly accepted this with EMTALA, but they still have not come to terms with it. It took the GOP 20 years to accept the New Deal, and Ike accepted it in entirety, making no effort to run and govern against it. I think the GOP in 2020, if they lose in 2016, will likely have made its peace with another liberal win.
What I find interesting about conservatives is that they are always on the wrong side of the current debate, but they learn nothing from the fact that they have been wrong and losing for a hundred years. Conservatives were against liberal ideals in the 1910’s, 1930’s, 1960’s, and the present. They now accept the prior liberal victories as the right outcome, but they don’t draw the logical conclusion about who is likely correct now.