There was a moment, early in the House GOP’s secret health care deliberations, when they reportedly considered doing something fairly radical and—under different conditions—very good. In Republicans’ haste to repeal every tax in the Affordable Care Act, their budget lines were hemorrhaging revenue, leaving them torn between taking health care subsidies away from millions of poor and working class people or finding a new revenue stream to limit the insurance coverage loss their bill would cause.
For a few days at least, they considered resolving the dilemma in favor of the latter option. Republicans floated a proposal to cap the tax preference for employer-sponsored insurance, which is financed with pre-tax dollars. In isolation, a policy like this would raise many billions of dollars, which, if spent correctly, would help weaken the onerous link between employment and health insurance.
In the context of the odious bill Republicans were considering, and of Republican politics more broadly, the idea couldn’t withstand even brief scrutiny, and Republicans reverted to the original plan of cutting Medicaid and individual market subsidies by a trillion dollars to finance a huge tax cut for the rich.
After Trumpcare breathes what are hopefully its last gasps, and new health care flashpoints emerge, Democrats should consider the preferences Republicans revealed throughout this process and reformulate their own health care thinking and messaging. Before push could become shove, Republicans concluded that the right future for American health care is the same one that existed before the ACA became law—and they framed it in terms of freedom.
But Democrats, if they choose to, could co-opt Republicans’ rhetoric to make a much more convincing argument that liberal health care policy increased Americans’ personal liberty.
Democrats in Congress have been fairly effective opponents of Trumpcare, but thanks to President Donald Trump, they haven’t had a particularly difficult job. Trump held an unseemly Rose Garden celebration when the Republican House passed its health care bill, then turned around and told Senate Republicans that the House bill was “mean.” Democrats seized on that admission. They have glued the term “mean” to every subsequent iteration of Trumpcare, and it will surely loom large in their midterm election campaign.
And rightly so.
No matter how you look at it, the basic tradeoffs at the heart of Trumpcare are unforgivably cruel. But for the most part, Democrats are using “mean” as a stand in for only one of the two main value propositions at the heart of Republican health policy: that distributing resources from the rich and healthy to the poor and sick is wrong. They have essentially ignored the second value proposition: that freedom means the freedom to beg your boss for health care, or fend for yourself.
There’s real political power in the correct argument that conservatives are “mean” because they aren’t charitable enough. But there is also power in the complementary argument that Republicans have coopted the language of freedom to impose a form of indenture.
President Barack Obama made a version of this appeal in his second inaugural address, as an implicit rebuke to his vanquished rivals, who crusaded during the campaign against moochers on government assistance. “The commitments we make to each other through Medicare and Medicaid and Social Security, these things do not sap our initiative,” he said. “They do not make us a nation of takers; they free us to take the risks that make this country great.”
This is especially true of the Affordable Care Act, which created an insurance system in parallel to the employer-sponsored system, so that working-age people who lose their jobs or leave their jobs don’t lose the entirety of their health insurance subsidy in the process. A more thoroughgoing national health care plan like Medicare-for-all, also known as single-payer, would sever the link between employment and insurance entirely and forever. But Obamacare weakened the phenomenon of “job lock” substantially.
Notwithstanding Obama’s second inaugural, the liberating aspects of universal health care have not been central to the Democrats’ value proposition, whether they’re fighting for expanding access to health care or fighting GOP efforts to limit it. The challenge for Democrats is to turn the GOP’s revealed commitment to maximal job lock into a liability.
By limiting the terrain of the health care fight to the moral dimension of fairness, Democrats were mostly unprepared to counter the disingenuous uproar that ensued on the right a few years ago when the Congressional Budget Office found the ACA lowered employment. Republicans brandished the report as evidence that Obamacare cost people their jobs, but the labor-market impact CBO detected was almost entirely a function of freeing people from jobs they would have already left but for the fact that they couldn’t go without health insurance.
“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,” then-CBO Director Doug Elmendorf told a House panel back in 2014. “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.’”
It is a testament to the Democrats’ discomfort on this moral plane that it fell to the director of the non-partisan CBO to deliver the strongest rebuttal to GOP spin. The question is whether six months of Republican squabbles have widened Democratic horizons. The GOP has laid bare a vision in which the government uses the universal need for health care as a perpetual lever to extract people’s labor regardless of their circumstances. Can Democrats sell the country on the opposite idea, that this yoke makes everyone less free?