This is the third in a four-part series on the Patient Protection and Affordable Care Act. In the first installment of this forum, Hussein Elbakri, of the Columbia Political Review, analyzed the arguments for and against the Affordable Care Act’s constitutionality. Next Noah Fram, of the Vanderbilt Political Review, discussed the Act from the standpoint of public policy, asking directly if the bill is “a normative good for society.” If we believe Hussein that the bill could be considered constitutional because it is a rational political solution to the healthcare problem, I hope I can jump off from that point and delve into just why the politics are so controversial. And if we rightly ask, as Noah did, if a better bill could have passed the House, we’re forced to come down from an academic perch and muck around in the dirty world of Washington politics a bit. While there are a lot of places where the monstrous bill could be cleaned up, the truth is that the broad outline of the ACA probably couldn’t have existed any other way because the core of the bill is very Republican.
Shortly after the Supreme Court’s oral arguments about the Affordable Care Act, I attended a healthcare policy forum in Washington, D.C. I challenged myself in the debate to support the bill’s individual mandate using only research and arguments produced by the Heritage Foundation, a bastion of conservative thought. It’s not too difficult: it requires little to no intellectual acrobatics to support, from a Republican perspective, Obamacare’s requirement to buy health insurance. As I was putting the data together, many fellow students were surprised that such a straightforward conservative case could be made to support a bill today’s conservatives seem to abhor. The trick, of course, is to recognize the difference between 1993 conservatives and 2009 conservatives.
The Republican Party is a collection of many varied conservatisms, all somewhat at odds with one another. Social conservatives, neoconservatives, libertarians, fiscal conservatives, and paleoconservatives all stress different values. For example, Rick Santorum’s socially conservative idea that government has a moral Christian duty to oppose abortion or gay marriage directly contradicts Ron Paul’s libertarian conservative position that government has absolutely no right to decide on such matters. Understanding the Republican Party’s shift from the traditional conservatism (or paleoconservatism as some might call it) of their 1993 healthcare proposal to the libertarian conservatism of the 2009 opposition to the very same proposal is vital to understanding the healthcare debate.
In the early 1990s, the Heritage Foundation, a bastion of conservative thought, released a series of proposals designed to counter Hillary Clinton’s proposal of a single-payer healthcare system. However, as the National Review’s Ramesh Ponnuru recently pointed out, libertarians then, just as now, were skeptical of the government requiring individuals to purchase a product. Sheer unadulterated partisanship explains part of their sudden rejection of the Obamacare bill. However, part of it is also strident libertarianism reacting to the spending excesses of neo-conservatism—a logically predictable intra-party power struggle.
The Heritage Foundation’s Stuart Butler, who now heads its Center for Policy Innovation, wrote two critical white papers—the first in 1989 and the second in 1992—both proposing healthcare reform centered around a requirement that all individuals buy insurance. The National Review’s Ponnuru may be correct that the iconic conservative magazine never formally endorsed the mandate idea and that parts of the party never did either. However, 19 Republicans and two Democrats are on the record co-sponsoring the Senate’s 1993 Health Equity and Access Reform Today (HEART) Act (SB 1770), the principal conservative answer to Hillarycare. Section F of that bill contained a “universal coverage” clause requiring every “citizen or lawful permanent resident to be covered under a qualified health plan or equivalent healthcare program.”
The conservative argument Butler makes for the mandate is a classic personal responsibility one: “society does feel a moral obligation to insure that its citizens do not suffer from the unavailability of healthcare. But on the other hand, each household has the obligation, to the extent it is able, to avoid placing demands on society by protecting itself.” It’s straight from the core of Republican orthodoxy.
The ACA was one of the most conservative ways to reform the US healthcare system: more conservative than Hillary Clinton’s original single-payer proposal, more conservative than President Obama’s public option proposal, more conservative, dare I say it, than Paul Ryan’s radically laissez-faire voucher proposal. I mean that in sense of Edmund Burke, the iconic 18th-century British Whig whose philosophical treatises are at the core of traditional conservative thought. Burke, who valued slow and measured incremental change to society’s institutions and a general belief in the power of tradition and habit, would have likely, in my opinion, supported the gradualism of expanding Medicaid rather than the libertarian radicalism of Paul Ryan’s alternative health voucher proposal. For better or worse, social welfare programs like Medicare and Medicaid have become American “tradition and habit,” and our society is more stable when we choose to thoughtfully reform these institutions than to slash them in favor of whole new ones.
Now if Burke dominates in the old elite circles of the Republican Party, Ayn Rand’s selfish rationalism is the guiding light for the thinking grassroots activists now flooding the party. The libertarians who favor her opposed the individual mandate as unconstitutional in 1993 when it was first proposed, and they’ve hardly changed their tune. They’ve gained more strength in a political environment with a pragmatic Democrat president eager to compromise. President Obama’s proposals appeal to Burkean conservatives who don’t have a knee-jerk negative reaction to any government action. The fact that the ACA’s gradualism appealed to Burkean conservatives and its deficit neutrality appealed to fiscal conservatives is not enough to counter intra-party inertia toward libertarianism, the most effective ground from which to attack the president they so direly want to defeat.
Of course, much of the Tea Party’s death panel and socialism rhetoric and similar statements not worth repeating have been thoroughly refuted in many forums, but I’d like to shine light on a more substantive libertarian argument: that the ACA limits our freedom.
Hong Kong, the top nation on the Heritage Foundation’s Economic Freedom Index, might be the best counter-argument. Its healthcare system is primarily publicly funded, very efficient, and hardly interferes with the laudable low-regulation libertarian policies that have made it a beacon of prosperity in Asia.
The next nine nations on Heritage’s list are Singapore (government-run universal healthcare), Australia (free universal healthcare), New Zealand (mixed public-private system), Switzerland (individual mandate), Canada (single-payer system), Chile, Mauritius, Ireland (two-tiered public-private system), and the United States (individual mandate by 2014).
How can economically freer nations than the US also be more “socialist?”