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Health Care

It Wasn't Rand

Reihan Salam points us to an old column by Mark Thompson post in which Thompson argues that conservatives usually failed to offer effective health care reform proposals because they were in thrall to the radical antistatism of Ayn Rand.  I think that is false and could lead to confusion about the course of the debates (over decades) that led to Obamacare.

I'm going from my personal experiences both as a consumer of right-leaning media and from conversations with conservatives over the last twenty years, but my impression is that the reason radically reforming health care has not been a huge priority for most conservatives (as opposed to some wonks and members of Congress) is because most conservatives were mostly happy with the existing system.  It seemed like a private system.  You worked for a private company that contracted your insurance to a private insurance company.  You went to your doctor who was not a government employee.  The system of tax subsidies and regulations that made this somewhat unnatural system  the default was mostly invisible.  You had access to timely and very high quality care.  You heard stories about lines and waiting lists in the socialized medical systems of Britain and Canada.  America had a system of private health care and it was the best system in the world.  Rand had little or nothing to do with it.  In fact, if you were to try to get all Randian and eliminate the tax subsidy for employer-provided health insurance for most conservatives and also Medicare for their parents (not replace them with other, more consumer-driven systems that include government subsidies, just get rid of them as Rand would want) most of these same conservatives would try to tear you apart - politically of course.

The system had problems.  For one thing, premiums seemed to be going up to quickly.  Both the left and right had explanations and likely suspects for the rise in premiums.  The suspects included greedy insurance companies, greedy trial lawyers, greedy pharmaceutical companies, illegal immigrants, and uninsured people who were clogging up the high-cost emergency rooms.  People mostly weren't told by conservative popularizers and mostly didn't want to hear that much of the spike in premiums was inherent in the system of comprehensive employer-provided health insurance that conservatives were defending from liberal attempts to "socialize" medicine.

That  isn't to say that conservatives weren't in favor of some changes or that the changes weren't worthwhile.  They were in favor of tort reform, regulatory changes to make it easier for small businesses to work together to buy insurance at lower rates, and regulatory changes that would allow people to buy a wider range of insurance products (including high deductible/lower premium plans) and bypass state-level regulations that were driving up the cost of health insurance.  I remember some mentions of Health Savings Accounts, but not in any detail.  But the conservative reforms weren't really the priority on health care policy.  Stopping the liberal Democrats from destroying America's best-in-the-world private health care system was the priority.  Oh, the Democrats are filibustering health care reform?  That just shows that the Democrats are in the pockets of the trial lawyers and don't really care about real health care reform.  Lets move on to cutting marginal tax rates.

In any analysis of how most conservatives acted on the health care issue from 1993-2010, I don't think you can overstate the investment of most rank-and-file conservatives to the existing system.  There were good (or at least understandable) reasons why the Republican congressional leaders offered a plan of tort reform and interstate purchasing of health insurance rather that the Ryan health care plan as their alternative to Obamacare.  That is where most conservatives probably are, and any plan that will destroy the system of employer-provided health insurance (which the Ryan plan would) will face intense public skepticism - including from conservatives who now get their health care through their employers.  And this gives some idea of the demands of finesse and public education that conservatives wonks and politicians will face in advancing the cause of free market-oriented heath care policy.

Categories > Health Care

Discussions - 2 Comments

Excellent post, Pete. I also think there's an understandable bias among conservatives to eschew radical reforms when a public policy regime, while somewhat dysfunctional, appears to be working.

So during the early 1990s, conservatives didn't object to the shift toward managed care so long as individuals were not mandated to purchase insurance. Managed care (in contrast to fee-for-service) indeed kept medical inflation in check initially. But once the early efficiencies were squeezed out of the system, costs continued to increase apace, to varying degrees because third-party payments insulated consumers from the consequences of their medical spending. (And employer-provided health care limits personal choice as well, since almost all employer-provided plans force workers to buy from only one provider.)

A more fundamental reform would be something along the lines of the McCain proposal, ending the income tax exemption for employer-provided health expenses. But like proposals to end the mortgage insurance deduction, many conservatives balk at that prospect because they fear the political backlash.

In other words, they'd rather keep a system in place that's popular but unsustainable over time -- so long as occasional tweaks seem to squeeze some savings.

Now, employer-provided health care might as well be considered an entitlement, at least in the eye of most people. Dislodging it will be every bit as difficult as making Medicare or Social Security sustainable in the long run.

Strange on a couple levels to me. Where has this guy been to find a flock of conservative Randians. I thought she was just as despised by them if not more so than by the left. I am curious if the use of Rand here is not some sort of esoteric device to conceal criticism of the entirety of enlightenment individualism meaning American founding principles. It would be a clever move to attack these principles while calling them Randian as this would ensure that only a few would dare to disagree and appear to be standing up for Ayn Rand.
It seems that the author is probably being dishonest in his casual introduction to the Hayek quote because I can see that the internet is littered with people using this exact passage to suggest Hayek supported some sort of a welfare state. The quote itself utilizes words like organize and assist rather than coerce and manage. I doubt very much that Hayek would offer neocons an alternative to cradle to grave coerced via the point of a gun sharing that would still be acceptable their grand idea of the community and also be easily associated with a narrow understanding of christian altruism. Is it still altruism when you force people to do it? I am amazed at how fast neocons rush to accept leftist morals and ends then wonder why no one wants to listen to them about they have a better means to get there. It is as if the world did not exist before the new deal at times and if not for our beloved step father the government half the country would be dead in a gutter by the end of the week.

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