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America needs to decide: is health care something we owe our citizens?

"If you can't afford health care, should the state let you die?" And other questions we're avoiding. 

A protest against Republican efforts to repeal the Affordable Care Act, in Los Angeles.
David McNew / Getty

What exactly are we fighting over when it comes to health reform? Is there really a fundamental philosophical difference between the parties’ positions? Does either party actually have a philosophy of American health care?

On the one hand, the difference between the parties seems clear: the GOP plan is basically a tax cut for the rich that takes health care away from the poorest Americans and leaves the states holding the bag. But, as a matter of structure — as opposed to generosity — the GOP plan may differ from Obamacare a lot less than it looks (setting aside the cruelty of its effects).

The House plan relies on government tax credits, regulation of the insurance industry, and continued government funding to keep the low-income population insured. In other words, it is a plan that relies on both government intervention and the private sector. And it walks a thin line between the idea that in a civilized society every person should have some health care and the opposite idea that you deserve only the health care you earn — and if you don’t earn enough, it’s okay if you suffer. In this respect, it is not that different from Obamacare.

This health reform debate, like virtually all the others that have come before it in this country, has failed to confront head-on the most important question in health. As a result, the end result will just be another Band-Aid. The fundamental question that every Congress from Truman’s to Trump’s has refused to answer is this: What is a health care system for?

Democrats and Republicans alike have always been disjointed about the basic purpose of a health care system. Whether we are talking about Obamacare or Ryancare, there is no overarching theory that sets out the fundamental values of American health care.

If two people are dying from the same disease, and require the same operation to survive, and one can pay and one cannot, is it okay for the poor person to die? After talking ourselves hoarse about health reform in this country for nearly a century, we still have no definitive answer to this question, because the main players in the debate keep dodging it. President Trump himself has said: “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” Well, it certainly will happen to a lot of people under the GOP plan — at least 10 million will be thrown off Medicaid according to the Congressional Budget office. But, it did also happen to some people under Obamacare — and happened to many, many more people before that.

The key to health care policy is finding a coherent balance between social solidarity and personal responsibility

There is a central tension in many policy debates — one with special salience in health care, given the life-and-death implications: the tension between social solidarity and personal responsibility (terms popularized in the health-care context by Wendy Mariner of Boston University). That’s what Congress should be debating: whether health care falls into the category of goods that individuals should either acquire on their own or go without. Instead, all of our modern political health debates are about changes on the margins.

To be sure, they are really big margins, with tremendous human cost: Millions of people would be affected by the Republican cuts. But the fights are not about what we think a health care system should be. On that question, we continue to straddle the line, insisting on an inefficient and fragmented hodgepodge of public and private regulation of health care because we are not comfortable with either option. Worse, we hide this hodgepodge in programs generally invisible to public view — like the tax subsidy for employer provided health care — so we never have a debate on the real issues.

Part of the problem, believe it or not, is communism. Ronald Reagan, in his efforts to torpedo Medicare in the 1960s, proclaimed government support of health insurance “socialized medicine,” turning a big part of the health care debate into one about the American capitalist ethos and patriotism. (Even before Reagan, the American Medical Association had been sounding this particular alarm). The resonance of Reagan’s message is an important reason why the United States is highly unlikely to ever have a single-payer system, such as a Medicare for everyone. It’s why we keep hearing the term “liberty” to — ironically — justify massive cuts that will have terrible effects on people’s lives.

To be sure, there are good-faith reasons to object to some socialized public policies, particularly the idea that relying on the market, rather than government, can lead to higher efficiency and better results. But we too seldom get to the point of analyzing whether that claim holds true in specific cases, because of the ideological baggage.

Since the 1940s, the US government has been deeply involved in health care, yet we pretend otherwise

The US government has played a far greater role in American health care, well before the ACA, than many people know or, in the case of pro-personal-responsibility conservatives, like to admit.

Many average, even rich, Americans may think that they get no federal aid in this area, but they probably do. They may disdain Medicaid — the low-income insurance program for the poor — but do they realize that approximately half of Americans get their insurance from private companies through work, and that system includes a substantial government “handout” too? We call this the “private payer” system, and it feels like capitalism, not socialism. Since the 1940s, however, US employers have been incentivized to offer health insurance through a massive federal tax exemption for that benefit. Indeed, our current system was largely created by that policy. But the fact that the government involvement is concealed makes it palatable to our ethos.

(Although an GOP draft bill flirted with cutting back on that benefit even slightly, the absence of any cuts from the final version brought to the House makes clear just how much well-off Americans, and employers, like their health-care handout.)

On the other hand, we do not give the same help to everyone. Do all single males making $10,000 annually get health care from the government? Most people think the answer is yes, through Medicaid. That’s wrong. Medicaid initially covered only mothers of dependent children, the disabled, and low-income elderly — the so-called deserving poor. While some states stepped up and voluntarily expanded their programs over time to include single adults, including men, many did not. As a matter of national health policy, in short, those adults were deemed undeserving of the community’s support until the ACA tried to cover them.

The Supreme Court stymied Obama on that front and made the ACA’s Medicaid expansion optional. So it was up to individual states to determine whether low-income single men deserved help. In states that answered that question with a “No,” we rely on charitable hospitals to pick up the slack for these uninsured — but the federal government makes special payments to those hospitals to compensate them. Which approach does that policy exemplify? Socialism or capitalism?

We are lying to ourselves when we refuse to acknowledge the role the federal government plays in all our health care. Kenneth Arrow, the Nobel Prize–winning economist who died last month, famously wrote of the impossibility of a true free market in health care, claiming: “Nobody is prepared for the idea of a laissez-faire system, and we never really had one.”

The result of philosophical confusion is a hodgepodge of policies

Look at all of our workarounds. We run our health insurance program for the poor through the states. We run our health insurance program for many workers though employers (who get tax breaks from the government for their efforts). We say we do not want the federal government meddling with the practice of medicine, but we have built our entire health care system around health insurance access — and we let insurance shape what procedures doctors do, what drugs we use, and even what doctors many of us can see. We say we reject government-sponsored health care, yet the all-federally-run Medicare program is one of the most popular and successful health programs we have.

The House Republican Plan perpetuates this philosophical mess. It repeals the ACA’s requirement that we all buy insurance, but then reinserts a similar idea through the subtler requirement that we all need to maintain insurance coverage with no gaps if we want insurance access. In other words, the government will still interfere and ask the insurance industry to abandon the basic economic model under which insurers make money in a free market: discriminating in pricing based on health risk. Then it gives them subsidies to make up for the lost money. That’s a long, long way from a pure market system.

The plan cuts back on Medicaid, but instead compensating states for these cuts by funneling more money to the hospitals that are going to have to see all the poor uninsured people in those states. That’s still government-subsidized health care — just even more hidden, inefficient, and stingy than it was under the ACA.

To be fair, Obamacare perpetuated this confusion. The ACA bent over backward to keep the “private” insurance system in place. Indeed, it anchored the statute’s success on that private industry — something for which the ACA is now paying the price, as insurers defect. At the same time, the ACA regulated the insurance industry as never before, and went further than any other health program in American history to push the needle toward social solidarity in its open goal of universal access to care.

Really, Obama had no choice. Congress would never have allowed a full federal takeover of the health care system. (Clinton’s plan made only modest moves in that direction, and it was a debacle.) It just isn’t the American way of legislating to scrap decades of incrementally added state and federal programs and start afresh. In the case of health care, however, incrementalism has had a particularly pronounced and unfortunate effect: It has produced layers of health programs — from Medicare and Medicaid, to the HMO Act and ERISA of the 1970s, to HIPAA and EMTALA in the 1990s, to the ACA — all reflecting different theories of equality versus individual choice, and all operated in different ways.

Without a single philosophy of American health care, we have had to keep layering to try to get the regulation we all know we need for our people while also maintaining the fiction that we can have a successful and morally fair health care system without government centrally in the picture. We have run far too much of health care policy through the back door of the private insurance system. Advancing social solidarity — which it is clear all Americans want to some degree — is really the work of government, even in a system that may always have some private components.

Confusion aside, Obamacare shifted US policies toward social solidarity

And so we find ourselves here again. We are in a better starting place than we were in 2008. The ACA’s greatest success lies in how much it tipped the scales in favor of social solidarity. No one is going to take health care away from all of the 20 million the ACA added. It is now the new normal to think, for example, that 26-year-olds should be insured and, in some states, that poor single men deserve health care, too. Even President Trump, as quoted above, embraced the new baseline Obama left behind, claiming everyone would be covered. And that baseline is a reason we have a healthy number of republican governors and senators now telling the House to slow down and rethink its thoughtless cuts. That’s a remarkable legacy for the ACA. It sounds a lot like solidarity.

The GOP plan will leave many people out, and will leave others with such skimpy financial assistance that the health care they have will be close to having nothing at all. That is the continuing tension between “us versus me,” and between government and the market, in American health care. It’s our enduring question and it’s clear that this round of health care reform, like all those before it, is not going to debate it openly and honestly.

Abbe Gluck is professor of law and faculty director of the Solomon Center for Health Law and Policy at Yale Law School.

The Big Idea is Vox’s home for smart, often scholarly excursions into the most important issues and ideas in politics, science, and culture — typically written by outside contributors. If you have an idea for a piece, pitch us at

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