One of the things that makes the debate over health care policy so interesting is that it has such sweeping implications. We can look at the issue, for example, and ask economic questions, such as, "How much is the Affordable Care Act helping the economy?" We can look at the same issue and ask fiscal questions, such as, "How important is it that 'Obamacare' is reducing the national deficit by hundreds of billions of dollars?"
We can look at the issue from a political perspective. And an ideological perspective. And a sociological perspective. And given extreme circumstances, maybe even a national security perspective.
But at its root, for many involved in the debate, the angle that matters is a moral one. Policies like the ACA tend to do extremely well on substantive questions, and quite poorly on political ones, but when we strip away the layers, we're often left with the morality of either providing or denying families access to basic medical care. Confronted with the question, either the dial on your moral compass spins or it doesn't.
This came up in a big way over the weekend, when the American Enterprise Institute's Michael R. Strain made a curious argument
about mortality rates in the Washington Post
. The headline on the piece read, "End Obamacare, and people could die. That's okay."
In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals -- including more cash for other programs, such as those that help the poor; less government coercion and more individual liberty; more health-care choice for consumers, allowing them to find plans that better fit their needs; more money for taxpayers to spend themselves; and less federal health-care spending. This opinion is not immoral. Such choices are inevitable. They are made all the time.
In fairness to Strain, he almost certainly did not write the jarringly callous headline, but he did write this quoted excerpt. In fact, his piece went on to say that if Republican policymakers successfully repealed the federal health care reform law, it "could" result in more American deaths, "but it clearly would not be immoral."
I can appreciate why Strain feels the need to make this case. For proponents of reform, there's considerable focus on consequences: if Republicans -- either on the Supreme Court or in Congress -- destroy the law, the potential for catastrophic shockwaves are quite real. As a practical reality, if millions of families are stripped of the benefits, an untold number of Americans will die unnecessarily. Their crime? They got sick.
For Strain, "a slightly higher mortality rate is an acceptable price to pay for certain goals," and the money that would have gone into medical care could be redirected to other priorities, such as "those that help the poor." Brian Beutler notices
one of the many problems with the thesis.
This argument about ends is concise, unobjectionable, and completely unresponsive to the situation at hand. If the Supreme Court eliminates ACA subsidies in three dozen states this summer, the federal government will indeed spend less on health care. But none of the other tradeoffs Strain lists will happen. The savings will not be plied into programs that help the poor or be returned to taxpayers, individual liberty will not increase, and a wider array of health plans will not materialize. Millions will lose their coverage, insurance markets will collapse, and the public dividend will be a slightly lower budget deficit. The moral implications of this outcome are hideous, both in the general sense that (thanks to conservatives) the government will have pulled an enormous bait and switch on a huge swath of the uninsured public, and at the specific level where many thousands of individuals took the bait, and made irreversible medical choices with insurance they were told couldn’t be rescinded. This is why the Supreme Court is now a death panel.
At the broadest possible level, Strain's overarching point seems fair, if not obvious: we don't invest limitless resources into protecting everyone at all times and in every instance. At some level, a degree of rationing is responsible (we wouldn't, for example, exhaust every possible resource to briefly extend the life of a 110 year old).
But as Jon Chait noted
, it's the applicability of Strain's thesis to the ACA where the argument struggles.
The first problem with Strain's argument is that it treats the banal case, that rationing medical care can be moral, as a blanket rationalization for any kind of rationing scheme. Yes, making choices about how to spend money on medicine is necessary, and those choices will lead to some otherwise preventable deaths. But suppose one policy were to deny medical care to members of one ethnic group while lavishing higher levels of care on everybody else. Would that be a scheme Strain would defend morally? Of course not. Some forms of rationing are easy to defend morally (say, limiting access to exhorbitantly priced treatments with meager or uncertain benefits). Other forms are harder to defend. Acknowledging the possibility of a difficult moral trade-off is the start of any serious reckoning. Strain oddly treats it as though it is the end. Rather than wade into the trade-offs created by repealing Obamacare, he simply asserts the conclusion is obvious: "Repealing Obamacare could -- although wouldn't necessarily -- result in more people dying. But it clearly would not be immoral." I don't understand how this sort of language ("it clearly would not be immoral") could be used to defend any moral choice. Moral choices are subjective by definition. Some people believe the level of medical deprivation caused by repealing Obamacare would be moral. Some people think it would be moral to force the staff of the American Enterprise Institute to engage in gladiatorial bouts to the death for our amusement. The problem here isn't that Strain offers the wrong answer but that he offers the wrong kind of answer.
There's no denying the need for trade-offs in any system, and I'd love to compare the trade-offs in the Affordable Care Act to those in the Republican alternative, but at present, the GOP plan does not exist -- despite more than five years of meaningless promises from party officials.
This relates to Strain's thesis, of course, because he seems to believe the destruction of the ACA -- leading to "a slightly higher mortality rate" -- would be acceptable in part because of a Republican solution that could help take its place. If Strain has seen this elusive, mysterious alternative, here's hoping he'll share it with the rest of us.