David Coates

Defending Health Care Reform – Again!

It has been very difficult in these last few days to decide whether or not to respond to the House Republicans’ first major political initiative of 2011 – their introduction and passing of the Repealing the Job-Killing Health Care Law Act. Why respond, when responding suggests that the initiative is sufficiently serious as to warrant a carefully crafted reaction? Why respond, and give the initiative a legitimacy it probably does not deserve? It has been very difficult to decide. The legislation’s title alone suggests that this week’s debate and vote was more about political theater than it was about serious legislative intent: that the prime incentive triggering the introduction of this legislation was less the transformation of the U.S. health care system than the pacification of the Republicans’ Tea Party base. But even political theater has its consequences, and even bad plays deserve a review; and this one definitely does, because it is now to be followed by a series of House Committees charged to chew away at the detail of the Affordable Care Act in ways designed to undermine its central purposes.

To those committees, and to the House Republican caucus as a whole, we need to say that they are in error on at least the following four things:

Wrong Title – Whatever else the Affordable Care Act does or does not do, it is not a job killer. It certainly will not cost 650,000 jobs, as Republicans have claimed:[1] and indeed to make that claim serves only to obscure the real job killers now operating on the US economy. When you design a health care reform that protects small businesses from extra health care costs, as the Democrats were obliged to do in order to get anything through a Senate subject to a Republican filibuster, you do create a boundary problem part way down the company-size ladder: the problem that as a small firm grows those protections diminish and reluctance to hire may creep in.[2] But the solution to that problem – a solution already embedded in the legislation now being rejected – is to pull health care costs down for all employers and to cushion the transition with extra help to firms as they grow. The Republicans have seized on this limited boundary problem as though it were the core of the legislation. It is not. Nor is it in any way either the cause of our current unemployment or the main driver of any greater unemployment to come. The roots of our current job shortage lie in the deregulated universe championed by the Republican Party when the White House and the Congress were theirs to command. A party more forthcoming on the real causes of current large-scale unemployment would have a stronger claim on our attention when bewailing the danger of limited potential job losses down the line. Given how strongly the Republicans identify with corporate America, however, it is unlikely that such candor will be forthcoming.

Wrong Claims – Moreover the Republicans like to claim that the Act will add to the size of the federal deficit. As it happens, the non-partisan Congressional Budget Office disagrees with them. According to the CBO, it is the repeal of the Act that would add to the deficit and to the cost of private health insurance.[3] Implementing it will save $143 billion over a decade and $1.2 trillion in the two decades to follow. Republicans don’t like those metrics so they have flicked the CBO calculation aside as merely “opinion”.[4] But the CBO is not a source to be picked up or discarded at will. It is the gold standard regularly used by both parties for the costing of legislation, so those who are prepared to live by the sword must occasionally also be prepared to perish by it. And in any case, the underlying premise of the deficit conversation is itself problematic: it is simply not true that the current size of the public deficit is a major cause of contemporary U.S. unemployment. What is more certain is that federal spending has helped keep levels of unemployment down, and that any over rapid reduction in  the size of the public deficit will only add discarded federal and state workers to the ranks of the private sector unemployed. Republicans don’t seem to mind adding to the deficit when forcing a continuation of the Bush tax cuts for the rich. Nor indeed do they seem to mind pushing for the deregulation of the very banking system whose irresponsible practices triggered our current mass unemployment. If “job killing” is really what Republicans want to avoid, they need to look more closely at the practices of those who fund them, not at the limited attempts by their opponents to make health care affordable for all.

Wrong labels – Moreover, there is something profoundly frustrating about the way in which Republicans regularly reject the Affordable Care Act as a piece of socialist legislation when in fact it is nothing of the kind.[5] The terms of the Act are no different from those already in place in the Federal Employees Health Benefits Plan in which all members of Congress can enroll, and all but six of the incoming Republican lawmakers have been very quick to insist that their health care coverage remains firmly in place. No socialist fears there apparently! Nor should there be, for the great beneficiaries of the Affordable Care Act, apart from the 32 million extra Americans who will under its terms eventually receive modest health care coverage, are not some faceless government bureaucrats. They are the private insurance companies that those individuals and their employers will pay for the privilege. It was Republican opposition that blocked the introduction of a single-payer system of the kind preferred by Obama the candidate. A single-payer system would not have been socialism either, but it would have given a greater role to public bodies in the control of health care costs and in the guaranteeing of health care quality. It would also have helped lessen the burden of health care insurance on U.S. businesses large and small, and been even less of a job killer than the insurance-subsidization alternative created by the Affordable Care Act. Republicans talk as though the Obama Administration is trying to move us towards a Cuban or an old-style Soviet health care system. They are not. They are moving us – slowly, of course, with many of the big changes not due until 2014 – towards a pale version of the insurance-based health care systems of Germany and France; and Germany and France manage to provide high quality health care to all their citizens while spending only two-thirds as much of their GDP on health care as we do, and while remaining highly successful capitalist economies.[6]

Wrong direction – But does this new crop of Republican lawmakers know anything about European health care systems; and if they don’t, do they care? I doubt it. It is the deep-seated parochialism and ignorance of so many of the Republican claims that is ultimately so dispiriting – claims anchored in apparently little or no knowledge of how successful health care systems operate elsewhere in the democratic world, and in little or no recognition of the problems of health care provision endemic to the process, no matter how organized. All health care systems face rising costs. All health care systems face choices between providing health care free at the point of use (so inviting overuse) or health care reflective of the costs of delivering it (so inviting access problems for those too poor to pay). All health care systems have to strike some balance between demand and available resources, rationing against criteria of need, timing and cost.[7] If you treat health care as a commodity – to be bought and sold just like an automobile or a tin of beans – you necessarily exclude from access to it those whose incomes are inadequate to the task. If you treat health care as something you buy only when you’re ill, you necessarily expose everyone to moments in their lives when their earning power is threatened by an illness too immediately expensive to heal. All health care systems have to create structures where the healthy finance the sick in a social contract that guarantees to those currently healthy similar coverage when their health declines;[8] and every health care system has to find ways of getting health care to the poor unless it wants a world in which the poor are left to suffer illness and premature death simply because they are poor. Inequality in America is at record levels right now, which is why market-based health care solutions raise such acute access issues. But as a country we are not so immoral as to let the poor die in the gutter or the sick starve in the street: which is why so many of the detailed changes in the Affordable Care Act are so popular even if the overall package is not.[9]

It will be remarkable if a Congress which possesses such strong health care cover for its own members eventually denies coverage to the rest of us either because we have a medical pre-condition (half of all Americans under age 65 – 129 million of us – currently have one of those[10]) or because we are unemployed (15 million of us are currently in that condition), or because we have the misfortune to be a young woman (and therefore liable to pregnancy). But just that set of denials is what the House voted for in January. With 50 million Americans now uninsured,[11] that vote had better be just political theater, or else we must conclude that this new crop of House Republicans have lost not simply their sanity but also their humanity – and who wants legislators as morally impaired as that?

[1] For the claim and its refutation in detail, see Lauren Kelly, The GOP’s 5 Most Absurd Lies About Healthcare Reform, Debunked; posted on AlterNet January 20, 2011: and available at http://www.alternet.otg/story/149598

[2] This possibility is well discussed by Robert Pear in his “In the Health Care Fight, a Political Focus on Jobs, With No Simple Answers,” The New York Times, January 15, 2011:  available at http://www.nytimes.com/2011/01/16/health/policy/16health.html

[3] The CBO, its preliminary analysis, reported to Speaker Boehner that repeal would cost $145 billion by 2019, $230 billion by 2012, and more after that. (Data in The New York Times, January 7, 2011). For the argument that it is repeal that will be the job killer, see David M. Cutler, Repealing Health Care Is a Job Killer, Center for American Progress, January 2011, available at: http://www.americanprogress.org/issues/2011/01/jobs_health_repeal.html

[4] On this, see David M. Herszenhorn and Robert Pear, ‘Republicans Are Given a Price Tag for Health Care Repeal, but Reject It,” The New York Times, January 6, 2011: available at http://www.nytimes.com/2011/01/07/us/politics/07cong.html

[5] In her speech in the House urging repeal, Michele Bachmann called the Affordable Care Act “the crown jewel of socialism.” Mike Pence referred to it as a “government takeover of health care lock, stock and barrel.” (cited in The Washington Post, January 19, 2011)

[6] For details on the German and French health care systems, go to Ezra Klein, ‘The Health of Nations”, The American Prospect, May 2007; and the Century Foundation, National Health Insurance: Lessons From Abroad, The Century Foundation 2008. They are available at http://www.prospect.org/cs/articles?article=the_health_of_nations, and


For the data on GDP share, see http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_37407,00.html

[7] The best discussion of these endemic issues is still to be found in Susan Giamo, “Who Pays for Health Care Reform? “ in Paul Pierson (ed), The New Politics of the Welfare State, Oxford: Oxford University Press, 2001. See also David Coates, Answering Back, New York: Continuum Books, 2010, pp. 114-31

[8] For the importance of that contract to the modern American health care system, see Jonathan Gruber, Health Care Reform is a “Three-Legged stool,” Center for American Progress, August 5, 2010: available at

http://www.americanprogress.org/issues/2010/08/three_legged_stool.html. See also David M. Cutler, The Simple Economics of Health Care available at http://www.bepress.com/ev/vol7/iss5/art2/

[9] The latest Washington Post poll found support for complete repeal down to 18 percent: available at


[10] Data from the Department of Health and Human Services, available at http://www.healthcare.gov/center/reports/preexisting.html. One in 7 Americans was denied coverage in 2009 because of their prior medical history. (data in The Wall Street Journal, October 13, 2010)

[11] Data from the Kaiser Foundation, The Uninsured: A Primer, December 2010, available at http://www.kff.org/uninsured/7451.cfm

David Coates holds the Worrell Chair in Anglo-American Studies at Wake Forest University. He is the author of Answering Back: Liberal Responses to Conservative Arguments, New York: Continuum Books, 2010.

He writes here in a personal capacity.

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