Conservative Ideology or American Health?

We're talking about hundreds of billions a year throughout the country. [Dollars saved by limiting Medicaid]  This is so much bigger by orders of magnitude than welfare reform because, let me just describe exactly what this bill does for conservatives.  This is why I'm so excited about it and this is why I think people need to see the forest for the trees.  We are de-federalizing an entitlement.  Block granting it back to the states and capping its growth rate.  That's never been done before. Paul Ryan on Hugh Hewitt's radio show, March 10, 2017, talking about the virtues of his plan to repeal and replace the Affordable Care Act.  Note that Ryan does not mention American health outcomes, but does indicate why he is excited about his healthcare bill: because of what it does for conservatives. Missing from the transcript above is the note of almost tremulous excitement in Ryan's voice when he talks about the hundreds of billions saved by cutting Medicaid and, "That's never been done before."  Also missing from the entire transcript and audio of the radio program is any notice that the Ryan healthcare plan will redirect hundreds of billions in savings from cutting Medicaid to tax cuts for the wealthy.

You're never going to win a coverage beauty contest when it's free market versus government mandates.  Our goal is not to show a pretty piece of paper that says we're mandating great things for Americans. Paul Ryan on the same radio show, in response to a question about the possibility that millions [24 million, according to the Congressional Budget Office (CBO)] will lose health insurance if his proposal becomes law.  Ryan is saying that government mandates under Obamacare force people to have coverage they don't really want.  So, according to Ryan, any numbers coming out of the CBO showing that millions will lose their health insurance under the Ryan plan are misleading.  Indeed, the CBO evaluation of the effects of Ryan's plan notes that in its first year, 2018, most of the 14 million person reduction in healthcare coverage will come from people dropping their coverage because there is no longer a penalty for not having coverage.  Of that 14 million, some would drop coverage because the penalty was the only reason why they had coverage in the first place.  The balance of the reduction in coverage would come from people who drop coverage because their premiums have risen, and they would not be penalized for dropping coverage.  The CBO finds that after that first year, loss of healthcare coverage will continue to rise, to 21 million in 2020, then to 24 million by 2026.  According to the CBO, most of this additional loss of coverage would come from cutbacks in Medicaid under the Ryan plan, not because people dropped coverage they didn't want in the first place.

Something is different about American politics today, compared with what it was when I was a somewhat politically aware young teenager in the early 70s.  According to my recollection, it did not used to be that either of the two major American political parties would say out loud, loud enough for their constituents to hear, things that for their own well-being politicians should not want their constituents to hear.  But now, on healthcare, Republicans, for example Paul Ryan, talk like their voters are not in the room, or if they are, they are in a deep sleep or coma, and you can say anything you want as loud as you want, it doesn't matter.

I don't want to fall into the trap of remembering past bad presidents as better than they were simply because our current president is so bad, but on the issue of health care, at least, Richard Nixon in 1972 was publicly more thoughtful, humane, and progressive than any Republican now in the House or Senate.  Herewith, an excerpt from Nixon's March 2, 1972 Special Message to Congress on Health Care:

To the Congress of the United States:

An all-directions reform of our health care system--so that every citizen will be able to get quality health care at reasonable cost regardless of income and regardless of area of residence--remains an item of highest priority on my unfinished agenda for America in the 1970s.

In the ultimate sense, the general good health of our people is the foundation of our national strength, as well as being the truest wealth that individuals can possess.

Nothing should impede us from doing whatever is necessary to bring the best possible health care to those who do not now have it--while improving health care quality for everyone--at the earliest possible time.

If you read Nixon's entire message to Congress you may note the absence of political ideology, and see instead a sober discussion of some of the facts relevant to improving healthcare in America.  Now, such a simple relationship with facts is beyond the capabilities of Republican leadership in Congress.  Now, it is not first a question of how to achieve goals that benefit the country and its people, but of first deciding whether the methods that might be used to achieve such goals are in compliance with alleged conservative ideology.  That is why Paul Ryan, voluntarily hamstrung by conservative ideology, has produced a healthcare bill that is not really a healthcare bill, but an anti-healthcare bill, that redistributes healthcare financing to the wealthy.

March 9th, at his weekly press conference, Speaker of the House Paul Ryan emphasized the conservative virtues of his new healthcare proposal, saying that the plan is a "conservative wish list," but did not say whether it was also a wish list for Americans who would like to get or retain healthcare.  Ryan went through the bullets of the plan's alleged conservative virtues, virtues that are meant to please Republican congresspersons who claim a conservative ideology, but that will be of little comfort to any American-- Democrat, Republican, conservative ideologue or otherwise, whose health insurance becomes more expensive or who loses health insurance if this new plan becomes law.

Ideology can be a fun thing I guess, until its cutting blade begins to point back at the ideologue, and even then it might be fun for observers.  But who really could lose health insurance and be consoled by knowing that the law that took it away has its ideological bona fides in order?  I'll answer that.  Very, very few.  So few that those few would probably need to be examined for the absence of an instinct for self-preservation, and if they have family who has lost healthcare to ideology and they're still ok with it, examine them for the absence of a heart.  Don't bother looking for compassion, they won't have it.

If you were watching the proceedings as Republicans unveiled their new proposal for healthcare reform, you will have noticed that the selling points did not seem to be that the law would lower health insurance costs for individuals, or that more individuals would be covered under the new law, or that healthcare quality would be improved.  In short, Paul Ryan's selling points should not be good selling points for Republican voters who may lose healthcare under the new plan.  Paul Ryan, intent on passing this legislation, and probably feeling that its passage would justify Republican claims that he is their genius policy wonk, seems not to care that his proposal, if enacted, probably would harm the health interests of millions of Republican voters.*  So Ryan addresses the self-proclaimed conservatives in Congress as if Republicans who need help with health insurance are not in the room.

Ryan is saying, implicitly, that conservative ideology is more important to him than the health of Americans, including those who elected him.  If the health of Americans were more important to Republican politicians than their claimed conservative ideology, then they would have announced at the outset that their goal was to get better healthcare for more Americans than ever before.  Unconstrained by ideology, they would have gone about attempting to achieve that goal.

Why Doesn't Ryan Care That Americans Will Be Harmed If His Proposal Becomes Law?

At least two things would be sufficient, each in itself, to cause Ryan to care about depriving millions of Americans (including probably millions of Republicans) of healthcare.  There is compassion, and there is wanting to get re-elected.  In the past, since compassion evidently is not consistently present across the spectrum of humanity, the most reliable inducement for an American politician to be concerned about voters was the possibility that voters would not re-elect the politician if they became aware that the politician had acted against their interests.

First, the question of compassion.  If Ryan's compassion had greater sway with him than his allegiance to what he believes are conservative values, he probably would not have proposed healthcare reform that is likely to hurt so many human beings.  But this is a personal issue for Ryan, one that he can deal with or not.  There is no constitutional requirement for a politician to be compassionate.  Admittedly, it might be useful to a politician to have compassion: it could allow them to better understand their constituents, and to anticipate voter concerns and needs, but as you may have noticed, a lot of politicians, some of them quite successful, are light as a feather now, untouched by compassion.  So, it seems perhaps, that for whatever reason, compassion might not be that useful to certain politicians now, especially if you are a politician in the business of catering to special interests and reforming healthcare according to alleged conservative precepts.  One can even see where in some political circles compassion might be seen as a sign of fatal weakness and a marker of inability to do what needs to be done.

The Founding Fathers of the American political system of representative democracy were famously realist, and skeptical about reliance on virtuous humanity to make their new nation work the way they wanted it to.  Hence, among other features intended to restrain human misbehavior, the Founding Fathers built checks and balances into their plan.  Probably the vote was intended as the primary check on misbehavior among the people's representatives, and as the major inducement for politicians to seek to impress voters that they are working on behalf of the voters and no one else.  As we know, quite a few complications and wrinkles have grown into the system since our beginning, but still, it seems that over just the last three decades the vote has lost some--maybe most--of the power it used to have to restrain politicians from brazenly harming voters.  And the vote doesn't have the power it used to have to induce politicians to impress their voters.  There has been a weird disconnect between voters and elected federal officials of both parties, but particularly of the Republican party.  This is clearly manifested by Ryan's healthcare bill.  What politician would have the audacity, one would even say the career death-wish,  to publicly advocate for a bill that results in 24 million more Americans without health insurance?  That is, a career death-wish if the system were working the way it was intended to work, with politicians wary of being punished by the voters.

Paul Ryan evidently fears no voter wrath, since in his 2016 re-election he won 65% of the vote while his nearest challenger got 30%.  Ryan has never lost a congressional election, has never even been in a close one, and his district was re-drawn in 2011 by Wisconsin Republicans to make his district even safer for him than it already was.  The phenomenon of Republican gerrymandering of state legislative and US congressional districts is nationwide since 2011, and is only recently starting to be rolled back by the courts.  Gerrymandered Republican safe districts nationwide could explain in part why Republicans appear to have been set free from some of their fear of voters.

Probably another reason why Republicans do not seem to be as sensitive as they once were to voter anger is that in some areas of the United States they have successfully suppressed the vote of those who have learned to be skeptical of Republican beneficence and are therefore unlikely to vote Republican.

Another factor in the disconnect between voters and their elected representatives may have something to do with the omnipresent fog of omnidirectional communication that today we all breathe, and that allows separate spheres of public reality to be formed, nurtured and strengthened for battle against one another.  This seems to be a fog dark and heavy with the potential for opinion manipulation, bordering, it sometimes seems, on mind control.  If voters' minds have been conditioned sufficiently not to see certain realities, for example, that a proposed healthcare reform may redirect hundreds of billions of dollars over 10 years to the wealthy while destroying healthcare for millions of non-wealthy Americans, then politicians who are so inclined can support this reform without fear of being called to account.

Whatever all the reasons are for it, the disconnect between voters and their elected representatives promises to plague for the foreseeable future any attempt to make good public policy that benefits non-wealthy Americans.

*The AARP, the American Hospital Association, the Federation of American Hospitals, America's Essential Hospitals, Families USA, the American Medical Association, the American Nurses Association, the American College of Physicians, National Nurses United, National Physicians Alliance, the Association of American Physicians and Surgeons, the American Academy of Pediatrics, MoveOn.org, American Bridge, Center for American Progress, and Our Revolution have all come out against the Republican proposal for reforming healthcare in the US.  Generally, the stance of these organizations is the same: they are concerned that enactment of the Republican proposal will not be good for the health of Americans.  As the National Physicians Alliance said in their statement on Affordable Care Act replacement, dated March 7, 2017, "The National Physicians Alliance opposes the draft Republican House bill revealed last night. We believe the drastic cuts it proposes to Medicaid, coupled with the substantial reductions in subsidies that helped millions afford healthcare would be extremely detrimental to our patients."

On March 13, 2017, The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) released their report of the cost estimate of the Republican plan to repeal and replace the Affordable Care Act.  According to the report, the CBO and JCT estimate that "in 2018, 14 million more people would be uninsured under the legislation than under current law."  By "2026, an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law."  Note that even though Republicans claim that Obamacare is in a "death spiral," the CBO projects that if Obamacare were left in place it would insure 24 million people in 2026 than its Republican replacement would.

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