A Health Care Mystery Explained

Ezra Klein is puzzled (or at least says he is; I suspect he understands it perfectly) by Republican hypocrisy on health care. For many years the GOP has advocated things that are supposed to bring the magic of the marketplace and individual incentives to health care: higher deductibles to give people “skin in the game”, competition among private insurers via exchanges — competition that would include reducing costs by limiting networks — and, of course, for cuts in Medicare. Now the GOP complains bitterly that some Obamacare policies have high deductibles, that it relies on the horror of exchanges, that some networks are limited, and that there are cuts in Medicare.

Klein suggests that Republicans are really upset by other aspects of Obamacare, but are going after the easy targets even though they’re attacking their own ideas. In a sense he’s right, but as I said, I suspect that he knows that the issue is both bigger and simpler than he says.

What underlies what Jonathan Chait calls the Heritage uncertainty principle? He describes it thus:

Conservative health-care-policy ideas reside in an uncertain state of quasi-existence. You can describe the policies in the abstract, sometimes even in detail, but any attempt to reproduce them in physical form will cause such proposals to disappear instantly. It’s not so much an issue of “hypocrisy,” as Klein frames it, as a deeper metaphysical question of whether conservative health-care policies actually exist.

The question should be posed to better-trained philosophical minds than my own. I would posit that conservative health-care policies do not exist in any real form. Call it the “Heritage Uncertainty Principle.”

Well, actually it’s pretty simple. The purpose of most health care reform is to help the unfortunate — people with pre-existing conditions, people who don’t get insurance through their jobs, people who just don’t earn enough to afford insurance. Cost control is also part of the picture, but not the dominant part. And what we’re seeing right now, in any case, seems to confirm a point some of us have been making for a long time: controlling costs and expanding access are complementary targets, because you can’t sell things like cost-saving measures for Medicaid and limits on deductibility of premiums unless they’re part of a larger scheme to make the system fairer and more comprehensive.

And here’s the thing: Republicans don’t want to help the unfortunate. They’ll propound health-care ideas that will, they claim, help those with preexisting conditions and so on — but those aren’t really proposals, they’re diversionary tactics designed to stall real health reform. Chait finds Newt Gingrich more or less explicitly admitting this.

Hence the rage of the right. Here they were, with a whole raft of ideas they could throw out, like chaff thrown out to confuse enemy radar, to divert and confuse any attempt to actually provide insurance to the uninsured. And those dastardly Democrats have gone ahead and actually incorporated those ideas into real reform.

Once you realize this, you also realize that people who warn that by opposing Obamacare Republicans are undermining their own proposals are missing the point. Yes, the Ryan plan to privatize Medicare looks a lot like Obamacare — but Ryan comes to Medicare not to save it, but to bury it, so the question of whether his plan could work is irrelevant.

There’s no mystery here; it’s just top-down class warfare as usual.