Americans deserve the best physical, emotional, and financial security their collective money can buy
Healthcare and healthcare insurance are not commodities traded on the free market and as such they do not yield to free market rules. This is not a matter of opinion or ideology, but a simple matter of fact. Let’s start with healthcare. In order to be a free market commodity such as an automobile, consumers of healthcare must be able to choose a combination of price and service that best matches their needs. However, in most healthcare situations, this choice is not and cannot be available. If you have a multiple fracture of your femur, you are enjoined from telling your doctor that you will settle for the cheap option of a simple cast, even if it leaves you with a permanent limp. You must accept the current standard of care, which involves things like multiple surgeries, CT scans, and titanium pins, leaving you without a limp, but with a bill for tens of thousands of dollars. You must accept this, because doctors are in turn enjoined from offering you substandard care; it is both unethical and illegal. There are exceptions such as dentistry, orthodontistry, ophthalmology, plastics surgery, etc. and in these cases a free market can and does exist.
Moving on to healthcare insurance. Insurance works when three conditions are met: a large and varied risk pool, the ability to predict, with mathematical precision, the probability of every insured outcome (this is known as actuarial science), and finally, the ability to place a cap on the policy value. Neither of these conditions are met when it comes to insuring the health of human beings. Even for very large and highly randomized pools such as the workforces of major corporations, the almost infinite variety of diseases and injuries that potentially afflict the human organism prevents the application of actuarial science in its true sense. Additionally, ethics considerations prevent the placement of caps on healthcare expenditures. Due to this fact, all American healthcare insurers already operate in an environment which is highly subsidized by the American taxpayer. Employer-provided healthcare insurance plans that most Americans enjoy, are akin to the supplemental health insurance plans that are available in countries like Israel that have multi-tier healthcare, with the fundamental tier available to all residents at no charge. These plans simply provide an additional level of service, such as private hospital rooms, shortened waitlists, choice of providers, and other supplemental services.
So welcome to reality: America already has government provided universal healthcare at the taxpayer expense. It also has a multi-tier system in which additional and improved services can be purchased for a price. A number of insurance plans, usually employer-sponsored, cover these additional services. The fact that Congress, and specifically congressional Republicans refuse to accept this reality and live in 1776 la-la land does them a tremendous discredit and prevents them from doing their duty to the folks who sent them to Washington.
The problem with healthcare delivery and pricing in America is one of lack of fairness. Certain groups enjoy highly discounted preferential access to the American taxpayer-funded universal healthcare system. These are the veterans (via the VA), people who have employer-provided healthcare insurance plans, retirees (via Medicare), and poor, marginalized, and disabled people (via Medicaid). This leaves out folks who are working class and employed, just not in a way that provides healthcare benefits. These people are the target audience for ObamaCare. They are also the voters who put Trump in the White House. The Affordable Healthcare Act (ACA) provides these Americans with access to the healthcare system that they, like all Americans, pay for with their tax dollars, albeit at highly disadvantageous and unfair rates. This unfairness is the fundamental flaw in the ACA; this law needs to be improved in a way that levels the playing field, providing this group of Americans with healthcare access that is in no way more expensive or less convenient than the other groups. Attaining this goal will be a historic achievement for the Trump administration.
However, nothing can be done when the healthcare debate is being held hostage by two extreme positions that are utterly divorced from reality. One the left, extreme socialists like Bernie Sanders are proposing free universal healthcare, but are unwilling to talk about the rationing of services that will certainly be needed to prevent the costs of this program from gobbling up the entire federal budget. On the right, libertarian Republicans like Rand Paul pretend that healthcare and healthcare insurance are simply commodities that if allowed to trade on the free market with minimal regulation will just sort themselves out. Senator Paul has nothing to say to a young mother whose baby has a hundred and two degree fever and who needs to choose between a visit to the ER and fixing the transmission on the family SUV. “Well, if you only were a better informed consumer, you wouldn’t be in this mess,” is a heartless and un-American thing to say to this mother.
Reality-based conversation about healthcare in America has to start with what kind of minimal healthcare standards, including rationing, can be tolerated in America. It starts with abandoning any pretense that access to healthcare is either a right or a privilege and with realizing that it is simply a government provided service, just like police protection or the civil court system. Like any government service, healthcare cannot be unlimited and unrationed; it can only be as good of a service as the American people are willing to pay for. If that means that critical procedures are delivered immediately and quality of life services such as hip replacements have waitlists, then that’s how it has to be. After all that’s how we deal with all other government services that make up our modern lifestyles.
As part of an iterative process, acceptable healthcare standards need to be priced and a funding mechanism for them developed. This mechanism should be have a levelling and yes, distributive, nature, including taxation on income, labor, and consumption. Thus, on the income side, employer provided healthcare benefits should be taxed as income; on the labor side, a new federal payroll healthcare tax should be implemented, and on the consumption side, a federal sales tax should be a part of the package. None of these ideas are “conservative”. All of them will be welcomed by Trump’s voters in the Midwest and in places like Kansas and West Virginia. No American family should experience financial anxiety due to the unaffordability of healthcare. A mother whose baby is crying from pain does not care about conservative principles. Neither does she care about “choice” or “meddling by government bureaucrats in her healthcare decisions”. What she wants to know is that her baby can receive best-practices healthcare without impacting her family finances in any way. It is time for America’s politicians to help that mother out by living up to that most American of virtues: fairness.