I’ve long believed that people in a wealthy society (such as our own) have a right to health care regardless of their ability to pay. To me, this arises from a Christian conviction (though certainly not an exclusively Christian conviction) that each human being has intrinsic worth as creature made in the image of God. This intrinsic value entails that the market can never be regarded as the ultimate arbiter of value: whether someone deserves an essential good like health care is not determined by their ability to pay for it.
That said, I’ve always been largely agnostic about the best means to achieving universal coverage. I supported the Affordable Care Act (“Obamacare”) as a positive step forward, and in many cases it has been a literal life-saver. But with yesterday’s vote in the House of Representatives we’re one step closer to undoing even the relatively modest accomplishments of the ACA.
The ACA, with its reliance on market mechanisms and private insurance providers, was designed in part to appeal to centrists and conservatives (not to mention to get the insurance industry on board). Nevertheless, Republicans opposed it from inception and have pledged to repeal it pretty much from the moment it passed. In conservative rhetoric it constituted a “government takeover,” planting us squarely on a slippery slope to the dreaded socialism. More basically, despite its technocratic and market-friendly design, the ACA works by redistributing wealth from the rich to the non-rich, opposition to which is a bedrock of American conservatism.
What this shows, to my mind, is that the GOP, at least in its present incarnation, will oppose any effort toward universal coverage that requires taxing the rich to pay for benefits for the non-rich. And given that the whole problem is that many people simply can’t afford insurance, it’s hard to envision a solution that wouldn’t require redistribution. Conservatives sometimes argue that a “free” market in health insurance would solve the problem of cost, but there are well-known problems with treating health care like any other consumer good. Moreover, the “free market” solution is something that doesn’t exist outside of conservative theorizing, while there are plenty of real-world examples of universal coverage being provided by governments or through a mix of public and private solutions. It’s also worth noting that the most successful portion of the ACA, in terms of increasing coverage, has been the expansion of Medicaid eligibility–the most overtly “socialistic” piece of the law.
Given the intransigence of the Republican opposition, there doesn’t seem much point anymore in trying to appease conservatives. Whatever the fate of efforts to “repeal and replace” Obamacare, Democrats and liberals have very little reason not to push for a more ambitious, single-payer-style program to cover everyone in the country. This, of course, was a centerpiece of Bernie Sanders’ unsuccessful presidential bid, and it’s been gathering additional support among progressive Democrats in Congress. Whether this can be achieved in one fell swoop is debatable. The most viable approach might be to gradually expand Medicare and Medicaid eligibility, perhaps supplemented by a public health insurance option like the one progressives originally hoped would be part of the ACA. (Hillary Clinton voiced support for bringing back the public option in her ill-fated campaign.) Either way, it seems clear to me that pushing for more direct public provision is the most equitable and sustainable way forward.
This all assumes, of course, that Democrats ever manage to win elections again.