The health care debate we’re not having, but should be

In a mostly good column on Singapore’s health care system (I say “mostly” because it ignores the role state-regulated prices play in keeping Singapore’s costs down), Ross Douthat offers as clear a two-paragraph summary of conservative health policy thinking as I’ve seen. It’s worth quoting in full:

In theory there is a coherent vision underlying Republican health care policy debates. Health insurance should be, like other forms of insurance, something that protects you against serious illnesses and pays unexpected bills but doesn’t cover more everyday expenses. People need catastrophic coverage, but otherwise they should spend their own money whenever possible, because that’s the best way to bring normal market pressures to bear on health care services, driving down costs without strangling medical innovation.

This theory — along with, yes, a green-eyeshade attitude toward government expenditures on the working poor — explains why conservatives think a modest subsidy to help people buy health insurance makes more sense than Obamacare’s larger subsidies. Republican politicians may offer pandering promises of lower deductibles and co-pays, but the coherent conservative position is that cheaper plans with higher deductibles are a very good thing, because they’re much closer to what insurance ought to be — and the more they proliferate, the cheaper health care will ultimately be for everyone.

This is, obviously, a health care debate we’re not having, and it’s worth being clear about why.

Reason No. 1: The coherent conservative position on health care is extremely unpopular. The most telling line in Douthat’s column is this one: “Republican politicians may offer pandering promises of lower deductibles and co-pays, but the coherent conservative position is that cheaper plans with higher deductibles are a very good thing, because they’re much closer to what insurance ought to be.”

Consider how remarkable that sentence is. Douthat is saying, sympathetically, that Republicans routinely promise a policy outcome 180 degrees from the one they’re pursuing. As much as politicians are lambasted as spin artists, this level of misdirection is rare, and for good reason — if you build public support for the opposite of the changes you want to make, those changes are unlikely to endure.

There’s a reason Republicans offer such self-destructive promises. Sparer plans with higher deductibles and higher co-pays are extremely unpopular. They’re the most unpopular part of Obamacare, which is why so many Republicans — including Mitch McConnell and Donald Trump — have used high deductibles as a cudgel with which to attack the law.

Republicans have used this unpopularity to their advantage, instead of trying to sell Americans on the advantages of high deductibles and laying the groundwork for the day when they might move the health care system in a more conservative direction. They are paying for that decision now, and they will suffer dearly for it if their plan actually passes.

Reason No. 2: Conservatives don’t agree on or prioritize health policy. Lanhee Chen, Mitt Romney’s former policy director, has argued that Republicans fall into three camps on health care. There are those who want to expand coverage, those who think coverage is a liberal construct and the correct focus should be on cutting costs, and those who don’t think the government should be involved in health care at all.

I’d add another dimension to his taxonomy: There are many conservatives — including some in all three camps — who really wish we were talking about tax reform instead.

The divisions in both ideology and interest on the Republican side help explain the debate we’re not having. The unresolved ideological tensions push Republicans away from emphasizing health care issues — why focus on issues that split your coalition? Then, the reality that health care is rarely the top issue for conservatives means there are few who want to do the difficult work of persuading the country that less insurance is actually better.

It’s worth thinking about tax cuts for wealthy Americans as a counterexample here. It, too, is an unpopular policy. But Republicans really agree on it, and they really care about it, and so an extraordinary amount of work goes into coming up with sellable and serious policy proposals, finding effective language with which to sell those proposals (“tax relief,” “the death tax”), and keeping wavering Republicans on board. (There is no analogue to Grover Norquist’s anti-tax pledge in the health care space.)

A debate over whether America should move towards high deductibles and catastrophic insurance would be a valuable debate to have. There are real arguments for the conservative position on this issue. But it’s not the debate we’re having, and that’s because conservatives are too scared, and too divided, to have it.