Schrödinger’s Elephant

The brain-twisting paradoxes facing Republicans on health care reform.

Illustration by Mark Alan Stamaty. Click image to expand.

One reason health care is so hard to talk about sanely is that it’s full of paradoxes. How does the United States have one of the best health care systems in the world, yet also one of the worst? Why do regions with the shoddiest health care pay the most for it? If we’re trying to save money on health care, how come we’re gearing up to pay roughly $1 trillion for reform?

Similar paradoxes plague both parties. But the questions facing Republicans as they navigate the health care debate are especially difficult. Here are some of the trickiest ones. If you really want to rattle a conservative’s mind, ask these:

Do you think health care reform is necessary?

The message on all sides is that yes, our health care system needs to be fixed. The United States already spends way too much on care—$1 out of every $6—and costs will only keep trending upward. More than 40 million Americans still don’t have health insurance. And many of those who need it are denied treatment for pre-existing conditions.

Republicans get this. The GOP alternative plan released in May hit all the right rhetorical notes, talking about the “broken” system in which patients feel “trapped” while doctors feel “torn” between business and medicine.

But when pushed, some conservatives will admit they don’t think it’s that big a deal. As Missouri Rep. Roy Blunt, the House minority leader, put it at a press conference last week: “About 83 percent of the American people think that their current effect coverage is either good or excellent; 83 percent.” He also challenged the notion that more than 40 million Americans lack insurance. “That number may be 45 million, but an awful lot of them could get insurance at work if they wanted to. An awful lot of them are healthy people under 30. But we’re not satisfied. Ten million people can’t get to the system now. We want everybody, including those 10 million people that don’t have access, to have access.” Translation: It’s a problem, but it’s not as big a problem as some people say. Still, I’m not saying it’s not a problem!

That view has policy implications, too. If you think we need to help only 10 million as opposed to 45 million, then an individual mandate—which would oblige even healthy young people to get insurance—doesn’t seem necessary. Even with a mandate, a small percentage of people slip through the cracks. (In Massachusetts, for example, 2.5 percent of people still don’t have insurance.) Blunt also manages to play down the urgency by citing customer satisfaction. Eighty-three percent—that’s pretty good! But it ignores the problem of rising costs necessary to achieve that satisfaction. The 83 percent figure Blunt cited refers to Americans’ satisfaction with the quality of their health care; when it comes to cost, satisfaction drops to 52 percent.

Aside from who’s right, the Republicans are in a fix. On the one hand, 77 percent of Americans say they think health care costs are too high—so the GOP wants to be seen as supporting reforms that reduce costs. But on the other, they don’t seem to think health care reform is all that necessary—it certainly wasn’t a priority in the last eight years. The result is a set of solutions—incentivizing prevention, choice, and accountability but requiring none of them—that may improve the system but don’t treat it as a crisis.

Doesn’t a public option actually increase competition?

Conservatives love markets. Markets require competition. So more competition is better, right? That’s essentially the Democratic argument for a public option: It would improve the health care market by providing competition for private companies and thus forcing them to make cutbacks they wouldn’t otherwise make. “Competition is good,” said Health and Human Services Secretary Kathleen Sebelius on Sunday. “You can write the rules for a level playing field.”

The conservative response is a combination of “No, you can’t” and “No, Congress won’t.” Government-run health care, they say, would have all sorts of unfair advantages. It wouldn’t have to advertise, so it would be able to offer lower premiums. Its insurance pool would be nationwide, giving it more leverage to negotiate prices. It wouldn’t need to create a massive reserve fund, which private companies maintain in case they go belly up. Plus, the government would never let its heath care plan fail, so people will feel more confident about it. (If these sound like arguments for a government plan, then you see the depths of the conservative logic vortex.) Unfairness, therefore, is inevitable.

Another argument against the public option-as-competition is that its logical endpoint—and President Obama’s stated best-case scenario—is a single-payer system. The result wouldn’t be government forcing private companies to improve their services via fair competition. It would be government picking which private companies succeed and which ones fail. And that is hardly market competition.

Doesn’t the government already run health care?

Next time someone tells you he’ll leave the country if it institutes government-run health insurance, suggest he buy his plane ticket today. Almost half of all health care spending in the United States is already government spending—think Medicare, Medicaid, SCHIP, and other state health programs. Meanwhile, the private health insurance market is one of the most highly regulated sectors of the economy, both on the state and federal levels. “They’re governed by telephone-book-sized books of regulations,” says Robert Moffit of the Heritage Institute. States dictate medical underwriting rules—for example, they can prohibit insurance companies from denying coverage—as well as specify which benefits get included in private plans. So in that sense, almost all private health insurance is “government-run.”

Sure, there’s a lot more the government could do—force you to enroll, favor one plan over another, set rates, etc. But a blanket condemnation of government-run health care ignores the fact that America is already halfway there. As Blunt put it, “with the federal government already $1.8 trillion in debt, would you really put that institution that’s already out of money in charge of your family’s health care?” Too late.

Is it possible to achieve universal coverage without mandating it?

No matter what your vision for health care, chances are it has the word universal in it. Democrats want “universal health care.” Republicans tout “universal access to affordable health care.” But the latter isn’t really universal. It’s basically saying we should reduce costs far enough that anyone who wants it can afford it. No one will argue with that. The problem, though, is that insurance works best when everyone buys it. When they don’t—and then get sick—everyone bears the cost. In order to make health care affordable, say Democrats, you have to eliminate the massive costs of treating people who aren’t insured. The best way to do that is to force them to buy insurance.

Mandating insurance thus does two things: It maximizes the number of people who have coverage, and it reduces the cost of insuring everyone. Sure, no plan is completely universal. You’ll always have some people who would rather pay a penalty than enroll. But if the goal is to insure as many people who want it as possible, you’re going to get a lot closer by requiring it than incentivizing it.

Wasn’t America’s first universal health care legislation signed by a Republican?

Mitt Romney created a migraine for the GOP by passing Massachusetts’ health care bill in 2006. He has since managed to blame the bill’s downsides—namely, its cost overruns—on a liberal legislature. But it’s harder for him to distance himself from the individual mandate. Now anytime Democrats need cover for mandating coverage, they can point out that even conservative Republican Mitt Romney supported it. (However, the Massachusetts plan does not include a public option.)Same with George W. Bush signing prescription drug legislation, the largest Medicare expansion in 40 years.

Of course, all these questions come with rejoinders or parallels for Democrats. Republicans may have trouble admitting that health care reform is necessary, but Democrats may have trouble saying they support a single-payer plan run by the government. If a public option really is market competition, then by supporting it, aren’t Democrats implicitly agreeing that market competition can improve health care? And if the government already runs so much of our health care system, then why is it so broken?

These questions may be easier for Democrats than the other questions are for Republicans, partly because Democrats don’t have to defend the status quo. Democrats also have first-mover advantage: Their proposals are driving the debate. Until Republicans come up with some plausible answers, they may find that most of America’s health care paradoxes work against them.