Why No GOP Health Care Bill Will Ever Be Really Popular

March 24, 2017

The conventional wisdom this morning is that Republicans are suffering a colossal defeat by failing to unify behind the American Health Care Act. It's only a colossal defeat if they let it become one. President Trump has offered a bold ultimatum: If the House doesn't pass the American Health Care Act, he's abandoning Obamacare. If this isn't a bluff to win passage and he genuinely means it, it means he's more reckless, more capricious, and more unworthy of conservative support than even his skeptics thought. A presidential declaration that repeal and replacement efforts are kaput for the remainder of his presidency would be the anti-Gorsuch, a giant vindication of his critics from the primary. He denounced Obamacare over and over again on the campaign trail. Now, in the face of predictable problems of a Republican party divided on how best to replace it, he's willing to abandon the effort?

Different Republicans are going to have different priorities in what replaces Obamacare. The U.S. health-care system is big and complicated and has a lot of problems because it's trying to address a lot of contrary desires. Americans want health care to be excellent, widely available, and cheap. Experience tells us we can only pick two of those qualities.

A gigantic lingering problem for any reform effort is that many members of the public have wildly unrealistic expectations about what their health care should be and how much they should pay for it, and no politician in either party has much incentive to be honest about hard truths. There's a strong argument that the entire concept of insurance doesn't work well for health care, compared to, say, auto insurance. The vast majority of drivers will not get in a major accident in any given year, and plenty of drivers will go years and years without an accident. Consumers are comfortable with a system where most years, they will pay in a considerable sum and get nothing from their auto insurer for that year.

Auto insurance works because a lot of people pay in and get little or nothing in return (other than peace of mind and meeting the legal requirements), but a few people pay in a little and then wreck their car, and the company can afford the costs of repairs or replacing it and make a profit on top, enough to run lots of ads with that little gecko.

Everyone needs health care eventually. And even if you're healthy and don't foresee health expenses in the near future, you can get hit by a bus or fall off a ladder or slice your finger with a steak knife at any time. (That's one reason why "preventative care" rarely saves as much as the reformers hope.) Obamacare decreed that insurance should cover birth control, which is a monthly expense. Quite a few Americans take prescription drugs regularly to control chronic conditions. Significant health expenses aren't as rare as car wrecks, meaning the insurers have to pay out more… which means they have to charge more in premiums.

The way to bring down prices in most markets is supply and demand, but that's difficult to apply to health-care costs compared to, say, shopping for a plane ticket on Expedia. If you're hit by a bus, you need emergency care and it's difficult to request the ambulance take you to the less-expensive hospital. People get very attached to the doctors they know and they've been seeing for years — thus the importance of Obama's pledge, "if you like your doctor, you can keep your doctor." Pediatricians watch kids grow up. People don't like the idea of breaking off an established care relationship and shopping around.

On paper, we can increase supply, and you've seen market forces improve health services not covered by insurance; LASIK surgery and plastic surgeries are the most-cited examples. But while you can increase the number of doctors in the country (and nurse practitioners, etc.) it's difficult to increase the number of the very best doctors. Even if we somehow forced medical schools to admit more students and produce more doctors, U.S. demand for health care is only going to increase as the Baby Boomers age.

The popular argument on the Left is to declare that health care is a right, and thus shouldn't be subject to the pressures of supply and demand. It's a lovely thought, until you start thinking through how this would work, because all health care is the result of someone's labor. Somebody's got to go through college and medical school and spend all those years studying to become a doctor or nurse or specialist. Somebody's got to research and develop the prescription medication. Somebody's got to invent, design, and build the MRI machine, robotic surgery arm, artificial limb, etcetera. And all of those people expect to get paid, and almost everyone would agree that considering their skill, education, talent, and hard work, they deserve to be paid well.

When you declare something is a right, it means it cannot be denied, particularly due to an inability to pay. Which means someone else, i.e., the government is in charge of payment.

Put aside the exorbitant cost of having the government pay for everyone's health care for a moment. You could argue the "government pays" system is close to what we have with Medicaid… except a lot of doctors find Medicaid payments to be way below fair market value, "around 50 to 85 cents on the dollar of the actual cost of medical care." Many doctors say that they're still willing to take the personal financial loss that comes from treating Medicaid patients, up until the point that they can't afford it. As of 2015, only 67 percent of doctors take Medicaid, and only 45 percent of doctors take new patients on Medicaid. Even the illustrious Mayo Clinic announced it is going prioritize non-Medicaid and non-Medicare patients.

The Democratic solution? Introduce laws forcing doctors to accept Medicaid payments. Some gratitude for the caring profession, huh? Making health care a "right" means that doctors are forced to work for reimbursement set by the government. It reduces them to tools of the state.

But this hasn't sunk in with much of the general public. They still believe that there's some system out there where they can get the very best care, choose any doctor they like, see any specialist they prefer, and pay little or nothing for it. And until that perception is dispelled, any health-care reform proposal will be greeted as a disappointment.

Man, This Thing Is Going to Become Redefined as 'Ryancare' Fast

Here comes the scapegoating:

Privately [President Trump] is grappling with rare bouts of self-doubt.

Mr. Trump has told four people close to him that he regrets going along with Speaker Paul D. Ryan's plan to push a health care overhaul before unveiling a tax cut proposal more politically palatable to Republicans.

He said ruefully this week that he should have done tax reform first when it became clear that the quick-hit health care victory he had hoped for was not going to materialize on Thursday, the seventh anniversary of the act's passage, when the legislation was scheduled for a vote.

Heavy is the head that wears the crown.

The End of 'Cute Kid Conservatism'

I concur with my friend Kurt Schlichter, who urges us to rekindle our appreciation for experience:

We need to dispense with the cute kid conservative novelty acts and understand that our ideology — unlike liberalism — is not based on feelings and preferences but is instead drawn from a wisdom and understanding of human nature that comes only from hard-won life experience. That's not to say young people should sit down and shut up — far from it. They have valuable insights we need to hear, especially from worlds they uniquely inhabit, like colleges or the company-level military. Sometimes they have done in-depth study and reporting on specific issues, including writing books. That's earned expertise, not some mere knack for viral ranting, and that's not what we are talking about here.

It's our own fault for letting them represent us to the world — maybe we do it because they flatter us by offering a dim reflection of what we believe. But when they recite conservative chapter and verse for us, that's all they're doing — reciting. It's not ingrained, it's not seared into them through study and experience. It's a stunt, a parlor trick. One of several reasons we conservatives need to stop putting them out there is because most conservatives have a youthful liberal phase and the kid who delights us today by mimicking our views will likely take a misguided off-ramp or two along the road to adulthood.

ADDENDA: Yesterday's Three Martini Lunch was one of our most Die Hard-focused episodes yet.

Actual headline in the Los Angeles Times: "Just like her mother, Chelsea Clinton never gets a break."

The Guardian calls me "a conservative blogger who is now a big presence at National Review." Weight-wise, yes.