gracchusdixit

After eight years of whining about the Affordable Care Act, a.k.a. Obamacare, Republicans have finally announced a plan to “repeal and replace” it.  Realizing how furious the backlash to their Puritanically cruel proposal is likely to be, they are doing everything possible to mask its consequences.  They have pushed preliminary “mark-ups” of the bill through two committees without the Congressional Budget Office having had the opportunity to “score” its costs or assess its effects.  They have also jiggered the timetable for implementing the bill to delay its most serious consequences until after the 2018 and 2020 elections, giving them time to do their worst without suffering at the polls.

Despite these evasive and obfuscatory tactics, the impact of what the Republicans are proposing is inescapably clear.  By the time its final pieces fall into place, the “American Health Care Act” will cause at least 15 million Americans to lose their health insurance, millions more will be shouldering higher costs, and the most vulnerable members of our society will be punished.  Those who are young, healthy, or rich will walk away with more money in their pockets, while corporate CEOs and insurance companies will get a huge tax break.  The old, the sick, and the poor will bear the brunt.  It is no exaggeration to say that more than a few of them will go bankrupt or die.  On top of all that, the deficit and national debt will skyrocket, since the Republican plan contains no plausible funding mechanism.

This proposal signifies far more than an attack on Barack Obama’s signature legislative achievement; it marks the culmination of their decades-old crusade to unravel every thread of the social safety net that was first stitched together by Franklin Roosevelt in the depths of the Great Depression and strengthened thereafter by many of his successors in the White House, both Democrats and Republicans.  This latest attack on our social contract nonetheless faces two hurdles.

One is that, now that millions of Americans have experienced its benefits, the Affordable Care Act is more popular than ever.  Without a replacement that leaves the most-appreciated provisions of the ACA intact—which are almost all of its provisions—Republicans are going to face the wrath, not only of Democrats, but of a large swath of their own voters, particularly those who most enthusiastically supported Donald Trump.  The states of West Virginia and Kentucky, for example, which voted overwhelmingly for Trump, top the list of ACA recipients.

The second hurdle is that the most conservative elements of the Republican Party are no less incensed than liberals by this legislation, albeit for entirely different reasons.  The so-called tea party, propelled by an avalanche of money from the Koch brothers, is lambasting the AHCA as “Obamacare Lite.”  Libertarians like Rand Paul are outraged that anyone, no matter how rich, should be taxed to provide healthcare to those who simply can’t afford it.  Congressman Mo Brooks of Alabama, one of the leading Luddites of the right, has condemned the AHCA as “welfare,” which, to people like Mo Brooks is, by definition, a dirty word.  All this leaves the Republican attempt to “repeal and replace” the Affordable Care Act twisting in the wind.

This shouldn’t be surprising, since the truth of the matter is that, when it comes to fixing what ails our healthcare system, Republicans are clueless and intellectual bankrupt.  Their justification for what they proposing is that the “market” will magically provide more “choice” and more “competition.”  This is disingenuous at best.  The only new “choice” the Republican bill provides is the choice to have no health insurance at all, which will make insurance more expensive for those who have it.  The only new “competition” the bill creates is to allow health insurance companies to operate across state lines.  This has been tried.  It produces no economic benefits and opens well-regulated state markets to shady operators and substandard coverage.

Even if all this were not the case, Republican belief in the “market”—a belief that amounts to the economic equivalent of revealed religion—blinds them to the reality that, when it comes to health care, the free market not only doesn’t work, it doesn’t even exist.

For a market to work properly, there are two requirements: transparency and a level playing field.  Buyers must have easy and equal access to critical information, and both buyers and sellers—or, in this case, providers and patients—must have roughly equal bargaining power.  Adam Smith, the founding father of capitalism, was the first to stipulate these conditions and the first to see that, without them, no market can operate freely or efficiently.  The problem, of course, is that neither of these conditions applies to the transactions between health care providers and their patients.

No patient, however well informed, is in a position to make truly knowledgeable decisions about vital medical procedures, and it is ludicrous to think a patient has the time or wherewithal to “shop around” before making them.  Inevitably, patients must rely on the superior expertise and good faith of their physicians.

Nor can patients reach their decisions on anything that even remotely resembles a level playing field.  By definition, the patient side of the equation, particularly when a serious illness is involved, is one of desperate necessity.  Thus, the notion that market-based competition and choice can produce quality and cost-efficient health care is an illusion at best or a scam at worst.

The more fundamental problem is that the American health care market isn’t a “free market” at all—and never has been.  Why can the CEO of  a local hospital, with no medical training, be paid a hundred or two hundred times the salary of a nurse with twenty or thirty years of experience?  Why can pharmaceutical companies charge prices for life-saving drugs that are a thousand times more than the cost of research and production?  Why can the typical orthopedic surgeon make half a million dollars a year—ten times the income of the average American family—and still complain that he or she isn’t rich enough?

It isn’t a “free market” that makes such decisions—it’s a system of de facto monopolies.  Professional guilds and associations limit the certification and supply of physicians.  Excessive patent protection limits the supply of  drugs.  Mergers and consolidation in the hospital industry drive competitors out of business and drive up costs.  If Republicans were truly interested in bringing competition to the business of health care, their bill would address and attack these market distortions.  Needless to say, it does nothing of the sort.

The current plan on offer in the House of Representative may not pass.  But if some version of it eventually does, Republicans will have succeeded in repealing and replacing the Affordable Care Act with an alternative that does absolutely nothing to provide better, more affordable health care.  They will live to regret the day.  Sadly, so will millions of Americans.