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The healthcare debate as mirror of a dispiriting presidential campaign


Despite the Republicans’ six-year obsession with repealing Obamacare, the healthcare issue has played a relatively minor role in this year’s presidential campaign. It nevertheless encapsulates all the themes that make this election such compelling theater – and dispiriting politics: the collapse of conservatism into incoherence, the retreat of liberalism into reaction, and the refusal of both parties to move their ideologies into the 21st Century.

Donald Trump, the likely Republican nominee, is many things, but there is one that virtually all leading conservatives agree he is not: a conservative. Yes, Trump advocates torture, restrictions on civil liberties, or a budget-busting tax cut aimed at the richest Americans – all policies of the Republican administration of George W. Bush. But he also defends “big-government” spending programs like Social Security and Medicare, popular with his otherwise-rightwing base that benefits from them. In the ultimate apostasy, Trump also says repeatedly that he will not let the poor who lack healthcare die in the streets. To understand just how unacceptable a position this is in conservative circles, contrast the subdued response to Trump’s statement at a recent GOP debate – just a small smattering of uncomfortable applause – with the rapturous reception given Ron Paul’s declaration during the 2012 cycle that we simply should let the uninsured die.

Trump has placed himself in the same straightjacket as all the other Republicans, however: needing to promise the complete repeal of Obamacare because, well, it has the name “Obama” in it. Unfortunately for the GOP, Obamacare – like Social Security and Medicare – contains numerous measures that are popular with its middleclass base. Apparently unaware that Obamacare has anything to do with these provisions, Republican voters – like most Americans – strongly support things such as coverage for pre-existing conditions and the possibility for young adults under the age of 26 to remain on their parents’ policies. 

Republican attacks against the healthcare law, then, generally follow a three-part approach: figure they will fudge these difficulties after they win the White House; formulate only thin nostrums as to how to replace Obamacare; and promise that, if only we returned to the antediluvian world where government didn’t interfere (which, their supporters don’t seem to realize, means repealing Medicare), everything would be alright.Trump has followed suit in all these respects. 

But the billionaire adds a different wrinkle: He has gone so far as to concede that the government should pick up the healthcare tab for sick and dying poor people. This has earned him the scorn of the “true” conservatives both in and outside the race.However, contrary to what his critics on the right like Ted Cruz argue, this doesn’t necessarily have to mean a single-payer (i.e., fully public, European-style) national health insurance system like that advocated on the left by Bernie Sanders. 

Conservative Arkansas, for example, adopted a “private option”, thereby taking the federal Obamacare money only to use it to provide private insurance for those eligible.Totry to help neighboring Louisiana, another conservative Southern state, to do the same,I provided its then-Republican governor with a plan to go even further and convert all Medicaid coverage to private insurance (you can read about it here).  Public payment needn’t mean public insurance. (The one other remaining Republican contender after Tuesday, John Kasich, is a rare Republican Governor who accepted the Obamacare money straight up, earning him the enduring enmity of his party.)

The crabbed and outdated view of government (and of the public-private dichotomy) reflected in the healthcare debate unfortunately extends to the Democratic side.Sanders, of course, argues for a return to universal, Big Government programs for health care and higher education.  Hillary Clinton counters by arguing against a single-payer system because it would supplant private insurance, instead backing incremental measures to reach the 10 percent of the population still uninsured. She frequently responds to Sanders in debates by noting that, “before it was called Obamacare, it was called Hillarycare.” This is a sure-fire applause line for her supporters because it symbolizes her long-time leadership, courage and progressive credentials – but Clinton herself doesn’t seem to mean it that way at all. Rather, it is a weary acknowledgement of the scars she suffered in her losing healthcare fight twenty years ago and her wariness – on this and so many other issues – of championing activist government.

Both the Sanders and Clinton approaches, then – like the Republicans’ determination to stick with the worldview of Barry Goldwater and Ronald Reagan, and keep fighting the last war against Barrack Obama – are rooted in the past.  They allmisconstrue the more complex direction in which the world is moving and the proper governmental response.

Take Sanders’ Medicare-for-All approach. This would undoubtedly be the best model for a government-based program; in my view, there’s no good reason the government shouldn’t offer all Americans the ability to buy into it. But we should still also have the right to buy private coverage, instead, if we prefer. In short, there should be both a “public option,” such as was proposed by liberals during the Obamacare debate, and the “private option” that dissenting conservative states have pushed for under Obamacare waivers. Americans similarly could be offered the ability to invest a portion of their Social Security (pension) payments in private accounts, as the right wants, if also allowed to keep those savings in secure US Treasury bills managed – at much lower cost – by the Social Security Administration, as liberals (and most Americans, if given the choice) would want.

Nobody in the political arena talks like this – it’s utterly outside permissible discourse – because it mixes up currently polarized either-or choices between government and the market. And that’s what misses the point: this is increasingly a false dichotomy. Thanks to a series of factors, like technology and entrepreneurial creativity, making many services more affordable and more easily accessible, people today have choices allowing them to opt out of governmental programs they don’t want, for options they consider preferable. In general, we consider freedom and choice to be positive things, and – as conservative theorist Kevin Phillips long ago argued – such opt-outs have long been the purview of every society’s wealthiest individuals; technology simply is democratizing many aspects of life today, and there’s no reason that won’t – or shouldn’t – include the choice of (heretofore) government services. 

But the opposite is also be true in many cases: the government-provided alternative may actually be the most appealing one, so much so that individuals may want to opt-in. Many people laugh at the notion of governments being efficient and competitive – but in many instances, they can in fact outperform and outcompete the private sector.Why not let them – and then let people buy whatever “government” they want? That way, we could all be Donald Trumps.