Because the Affordable Care Act is far from perfect, there are many fair-minded conservative criticisms of it, and a few plausible conservative ideas to either mold Obamacare into something different than it is today or phase in a comprehensive alternative and phase out those parts of the ACA that don’t fit into the new system.
Michael Strain, a conservative scholar at the American Enterprise Institute, has tendered such a plan. There is nothing immoral about it, and Congress wouldn’t necessarily be behaving immorally by adopting less generous federal health spending programs.
The challenge for conservatives, though, isn’t just to identify preferable health policy ends—it’s also to chart a path from here to there that doesn’t impose mass suffering on current beneficiaries. Conservatives have done neither, and for this reason their critics have described their health care posture in withering moral terms. Strain’s purpose in this Washington Post op-ed is to defend conservatives from those critics. He fails not because conservative health policy ideas are inherently immoral, but because he must gloss over the fact that the right’s current approach to implementing them is abominable.
As a political matter Obamacare probably can’t be repealed outright anymore. Any repeal bill would have to move in increments, and replace the ACA system with something that doesn’t dramatically reduce coverage. But Strain also notes that conservatives might “have their way with Obamacare” if “the Supreme Court deals it a death blow.”
Absent a viable alternative, which does not exist and isn’t in the offing, wishing for this outcome is morally dubious, and Strain’s counterclaim is unusually weak.
In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals — including more cash for other programs, such as those that help the poor; less government coercion and more individual liberty; more health-care choice for consumers, allowing them to find plans that better fit their needs; more money for taxpayers to spend themselves; and less federal health-care spending. This opinion is not immoral. Such choices are inevitable. They are made all the time.
This argument about ends is concise, unobjectionable, and completely unresponsive to the situation at hand. If the Supreme Court eliminates ACA subsidies in three dozen states this summer, the federal government will indeed spend less on health care. But none of the other tradeoffs Strain lists will happen. The savings will not be plied into programs that help the poor or be returned to taxpayers, individual liberty will not increase, and a wider array of health plans will not materialize. Millions will lose their coverage, insurance markets will collapse, and the public dividend will be a slightly lower budget deficit.
The moral implications of this outcome are hideous, both in the general sense that (thanks to conservatives) the government will have pulled an enormous bait and switch on a huge swath of the uninsured public, and at the specific level where many thousands of individuals took the bait, and made irreversible medical choices with insurance they were told couldn’t be rescinded. This is why the Supreme Court is now a death panel.
Strain compares this to other deadly, less controversial, policy interventions, but his main example—speed limit increases—badly undermines his premise.
“[T]here are huge (if dispersed) benefits to a 70 mph speed limit over a 10 mph limit: a transportation sector that can deliver goods quickly across the country; increased productivity, because millions of commuters can spend more time at work than in transit; and more time at home with our children.”
In trying to strike an appropriate balance between risk and benefit, governments vary speed limits, and when they increase speed limits, fatalities increase. But no speed limit that I’m aware of has ever been bumped from 10 mph to 70 mph. Speed limit changes occur at the margins, creating small changes in risk and reward. Eliminating Obamacare subsidies for millions of people would not be a marginal change. To build upon Strain's comparison, it would be akin to repealing speed limits.
Conservatives understand the difference perfectly well. Some on the right have spent the past week attacking President Obama for proposing to balk at a deal that provides a tax subsidy to mostly upper-income families saving up to pay for college tuition. Conservatives want to enact sweeping changes to Medicare, but they don’t propose repealing that program and then replacing it at some later date. This is partly because any party platform that included outright Medicare repeal would lose, but it’s also because conservatives recognize that it would be an immoral way to treat elderly people who budgeted their retirement savings with the expectation that their medical bills would be mostly covered. The moral and political implications parallel each other.
But that’s exactly what conservatives want to do with Obamacare. It’s not inherently immoral to be of the opinion that ACA dollars would be better spent in other ways, or to build political support for those goals. It is immoral to commit yourself to achieving them by any means necessary.