It is very hard to identify a single, coherent account of the Republicans’ Obamacare alternative from its authors and promoters. Depending upon whom you ask, the American Health Care Act would increase coverage, reduce coverage, or not affect coverage much at all; either the Congressional Budget Office analysis of the bill’s effect on insurance rates and the budget is not credible or highly promising.
But every supporter of Trumpcare seems to agree on one thing: That it will increase Americans’ freedom, relative to their lives under the Affordable Care Act. “People are going to do what they want to do with their lives,” House Speaker Paul Ryan said on Sunday.
Republican appeals to freedom are often amusingly circular; the party coopted the language of liberty long enough ago that they deploy it unthinkingly. If Republicans are for it, it must increase liberty. Under the terms of the AHCA, 14 million people will lose their insurance almost immediately, in many cases because higher premiums and lower subsidies will make health plans unaffordable. This is a weird way to define liberty.
But its Republicans strongest arguments for the AHCA, rather than their weakest ones, that reveal their conception of liberty and freedom to be exceptionally callous. Obamacare supporters now have an opportunity to reclaim those terms.
Three years ago, pretty much every Republican currently trying to enact Trumpcare was claiming vindication, based on a CBO report finding that the ACA would reduce employment by the equivalent of over two million jobs. They had at last found indisputable evidence that Obamacare is a job killer.
Republicans framed this finding as a frontal assault on liberty. They had no compunction about omitting the CBO’s stipulation that “the estimated [employment] reduction stems almost entirely from a net decline in the amount of labor that workers choose to supply, rather than from a net drop in business’ demand for labor.” Nor did Republicans heed Doug Elmendorf, then the CBO director, when he expanded on this point in subsequent Congressional testimony.
Can I say Congressman, the reason that we don’t use the term lost jobs is there is a critical difference between people who would like to work and can’t find a job, or have a job that is lost for reasons beyond their control, and people who choose not to work. If somebody comes up to you and says, well, the boss said I’m being laid off because we don’t have enough business to pay me, that person feels bad about that, we sympathize with them for having lost their job. If someone comes to you and says I’ve decided to retire, or I’ve decided to stay home and spend more time with my family, or I’ve decided to spend more time doing my hobby—they don’t feel bad about it, they feel good about it. And we don’t sympathize, we say congratulations. And we don’t say they’ve lost their job, we say they’ve chosen to leave their job.
To be slightly more technical about it, Obamacare reduces labor through two channels. The largest by far, as CBO explained, is an “income effect,” by which health insurance subsidies provide people enough income support to unlock them from jobs they no longer want. The smallest is through a “substitution effect” whereby people become disinclined to work longer ours or seek promotions, because they’d prefer to keep their untaxed insurance subsidies rather than allow them to phase out in exchange for higher, taxable wages.
Paul Ryan and the rest of the GOP could have accepted the first phenomenon as a form of liberty, and set about seeking a relatively narrow solution to the second phenomenon. Instead, they have decided both effects are bad and are attempting to eliminate them, effectively by increasing the extent to which people are indentured in the workforce by the threat of medical bankruptcy.
Perhaps the single most radical difference between Trumpcare and Obamacare is that the former largely severs the link between insurance subsidy and income. It accomplishes this, though, not by giving everybody enough money to afford their premiums, but by making insurance unaffordable to millions.
If you’re self-employed and were insured through the ACA, Trumpcare might remove a work disincentive, but it would most likely do so by removing your insurance altogether. If you left your job because Obamacare freed you to start a business or raise a child or retire early, Trumpcare might well draw you back into the workforce against your will, because being uninsured isn’t an option.
The controversy surrounding Trumpcare, intensified by Monday’s CBO report, has empowered a populist minority in the GOP to speak up against this perverse conception of freedom.
Christopher Ruddy, the CEO of the right wing site Newsmax and a personal friend of Trump’s, weighed in Tuesday with seven suggestions for Trump to revive Trumpcare, including the following: “Reject the phony private health insurance market as the panacea. Look to an upgraded Medicaid system to become the country’s blanket insurer for the uninsured.”
Converting Medicaid from a safety net for the poor into a safety net for anyone who finds themselves uninsured is an idea that would be very popular with Trump supporters, and is thus under consideration by nobody with any power. Where Trumpcare is practically optimized to screw over Trump’s base, replacing the Obamacare with a Medicaid-for-all option would eliminate the ACA’s narrow disincentive to work harder while continuing to free motivated workers to voluntarily leave their jobs.
It would be genuinely liberating. Not in the sense proffered by GOP Congressman Jason Chaffetz, that people would be free to forgo buying iPhones until they can afford bad insurance; or in the sense that it would give millionaires a big tax cut; but in the sense that the fear of injury or bad health would no longer be a tool the government uses to scare people into keeping jobs they’d otherwise leave.
Trumpcare, by contrast, enshrines indenture as a facet of personal liberty. As a governing philosophy, it is the freedom to work until you die. And if it weren’t for Medicare, it may well be the freedom Trump and Ryan would bestow on all of us.