Reihan Salam has a long Slate article explaining why Republicans generally want to repeal the ACA, conceding that have no actual alternative to the ACA with any possibility of generating consensus with the party, and…not really dealing with the implications of the latter. The article does serve one useful purpose in explaining why there’s nothing “conservative” about the ACA. The section on Paul Ryan wanting to end Medicare is particularly useful in illustrating why assertions that the ACA is “neoliberal” are so nonsensical. If the status quo ante had been single-payer, it might make sense, but in the actual context calling the ACA “neoliberal” makes about as much sense as calling the Clean Air Act or Civil Rights Act “neoliberal.”
The key to Republicans on health care lies in Salam’s assertion that “[c]onservatives tend not to be enthusiastic about redistribution.” Brian Butler has a good response, and DeLong really gets to the heart of the issue:
As I see it, there are three possibilities:
1. Poor people don’t get to go to the doctor–and die in ditches.
2. Poor people get to go to the doctor, but the doctors who don’t treat them don’t get paid and have to scramble to charge somebody else via various forms of cost-shifting.
3. The government subsidizes insurance coverage for people of modest means by raising taxes on people of less modest means.
In my view, Slate’s editors seriously fell down on the job in not requiring that Salam say whether he thinks it is better to go for (2)–imposes in-kind taxes on doctors–or (1) rather than (3). The view on the left and in the center is that (1) is a non-starter. As Margaret Thatcher said back in 1993 when she visited Washington, DC: “Of course we want to have universal health care! We aren’t barbarians!” The view on the left and in the center and on the not-insane right is that (2) is profoundly dysfunctional and would prove extraordinarily inefficient. If Salam prefers (1), he should explain why Margaret Thatcher was a squishy leftist. If Salam prefers (2), he should explain why he disagrees with every single technocrat who knows about the health-care financing system.
Exactly right. If you don’t believe that non-affluent people should simply be left to die needlessly from illnesses and injuries, you have have to believe in redistribution. The only question is whether it will be relatively efficient and equitable or grossly inefficient and inequitable. (Given that Salam implicitly favors the latter, his assertion that conservatives are “particularly skeptical about redistribution that isn’t transparent” can only be seen as black comedy.)
The other striking thing about Salam’s article is how blind all the hand-waving about “markets” is to both theoretical and empirical objections. The cliches about how markets will control health care costs seem to be unaware that Ken Arrow ever existed. And more importantly, you would think from Salam’s article that health care policy was uncharted territory, that the problems presented by the American health care system in 2009 had never been addressed anywhere. In fact, every other liberal democracy has addressed them in ways that provide universal coverage for less and often much less money per capita than the American system. The burden of proof evidently lies squarely on those who would “solve” the problems of American health care by taking us further away from systems that produce better outcomes for less money. For obvious reasons, Salam just omits the discussion entirely.