In the past few weeks we've heard a lot of ideas about the future of health care. Rep. Paul Ryan put out a plan to convert Medicare into a voucher system, Medicaid into a block grant and the new health care law into a distant dream. President Obama responded by doubling down on the health care law and setting a goal for an even tighter limit on Medicare expenditures. All this theater follows a couple of years’ worth of fights on the mechanics of health care reform. Obscured in all of this is the central question: Will your plan lead to universal health care?
This question is fundamental because it frames the solutions that are being offered. Our political leaders loudly proclaim that they want to make health care more affordable so that more people can get it. The vagueness of this claim means that we have no idea which people they think should have access to health care. Everybody? The rich? The sick? The employed?
Ryan has stated numerous times that he wants free market solutions to make health care available to all. In a free market there are winners and losers but the problem is that the consequences of being a loser in the health care market are dire. More importantly, we have decades of experience with people getting their health care through the free market and it has been an abject failure in getting us to universal health care. Projections of the effects of his plan show that in addition to the roughly fifty million people who would be uninsured due to repeal of the health care law, the changes to Medicaid in the near term and Medicare in the long term would throw millions more onto the rolls of the uninsured. So the question is, Is Ryan deluding himself about the power of the free market or is he misleading us?
The health care law that Obama shepherded into existence will expand our current system to give tens of millions of people access to health care. Though it is estimated that about thirty-two million more people will be insured under, that still leaves about fifteen million people without coverage. Left out are those who truly can't afford the premiums, undocumented immigrants and the conscientious objectors who take a fine instead of getting insurance. Excusing those who can't afford the premiums is folly and excluding undocumented immigrants is immoral and both reflect a failure to stand up for those with the least powerful voice. The only halfway reasonable exemption is to the few who do not want health care coverage, which is bad for public health but is politically wise*.
On the one hand you have a conservative plan whose goal is to place an even greater emphasis on the free market with the consequence that millions more are likely to be uninsured or underinsured than is currently the case. On the other hand you have the Affordable Care Act that, though imperfect, significantly moves the bar towards universal coverage while using the free market to achieve that goal. The tension between these two approaches is that each is setting out to solve a different problem which is why it’s nearly impossible to reach a compromise. Which plan you prefer depends on which problem you feel is more important, expansion of free markets or universal health care. Which plan you prefer depends on the question that drives you.
*For the Matrix fans, think along the lines of the Architect allowing, or rather needing, Zion to exist.