There’s been much ado about Donald Trump’s statement that “nobody knew that healthcare could be so complicated.” Before I get to the real point I want to make about this, let me just say something about these phrases: “A lot of people are saying,” “more than anyone has ever seen,” “no one can believe,” “bigger than anyone even knew.”
He uses these constantly. CONSTANTLY. These are the kinds of things you say when you need to impress but haven’t even bothered to fabricate any supporting data. They are utterly meaningless, content-free claptrap. They are almost always demonstrably false, but not the sort of thing that smart people waste anytime “fact-checking,” because the language is understood to be low-brow idiomatic and because it would be pretty absurd to report that “In the five or so minutes we spent working on this, we found no fewer than a dozen people who actually do believe [insert thing Trump said no one can believe].”
But that’s not really what I wanted to talk about here. What I want to do is push back a little against the notion that healthcare is really as complicated as Trump and the GOP would like us to believe.
Healthcare, as in the services provided by medical professionals is certainly complex and requires extensive learning and experience, but that’s not what Trump is talking about. He’s talking about the problem of ensuring access to healthcare for all Americans—and basically he’d just like us to know that it’s just too complicated for the plebs to understand so we should all please kindly just trust him and Paul Ryan and Mitch McConnell to provide a tremendous plan that we’ll all really love.
This is a fun little trick for pulling the wool over peoples’ eyes and Republicans have been doing it in the healthcare debate for decades now. They’ve completely obfuscated the very simple yes-or-no question that lies at the heart of the debate. It’s a question that they don’t want to answer because both responses make them look bad; “yes” reveals them to be heartless bastards, while “no” invalidates everything they’ve ever claimed to believe on the subject.
I’ll get to the question by way of a short hypothetical:
Imagine a person we’ll call Willis. Willis has been a fall-down drunk asshole for as long as anyone has ever known him. He’s belligerent, violent, vulgar and mean. It’s easy to see how he ended up living all of his adult life on the streets. He’s ungrateful and rude to those who try to help him. Willis just plain sucks.
One night, in his usual state of stumbling blind inebriation, Willis walks in front of a bus and is grievously injured. He needs two things—transport to a hospital and immediate medical treatment—neither of which are “free,” (which is to say that while there is obviously a cost associated with police and fire department response, no one will be presented with an invoice for this specific incident).
The entirety of the real healthcare debate lies in the question of what you think should happen to Willis at this moment.
Free-market orthodoxy would dictate that if Willis is unable to pay (or unlikely to be able to pay, i.e. with credit) for the services he needs, no one is obligated to provide them. Willis made a lifetime’s worth of bad choices that led to his current predicament. Why should anyone provide tens of thousands of dollars in products and services to an indigent jerk who will never pay a nickel for any of it? This is an extremely compelling argument. I happen to disagree with it vehemently, but it is nevertheless rational, idealistic and worthy of being given voice and consideration in the debate.
Having said that, anyone wishing to take that position must be willing to extrapolate out consistently from the relatively easy case of Willis to less tidy hypothetical cases involving human beings who are more inherently sympathetic than Willis—people whose life choices have been more relatable, people who have fallen on hard times under circumstance beyond their control, people who have young children, etc. The vast majority of cases involve individuals and families who are more likable than Willis, but the fundamental facts of those cases are, when you get right down to it, identical to his: someone needs products and services they cannot afford; the free market demands that they be denied those products and services.
If you are unwilling to make that argument, you have wholly abdicated the free market position. The moment you admit that you are unwilling to let Willis or any other hypothetical or real person go untreated for inability to pay, you have become a socialist where healthcare is concerned. In terms of policy, a person simply cannot hold that a single mother working three jobs to stay afloat should receive treatment for ovarian cancer while Willis should be denied care—unless of course you want the government to get into the business of making value judgments about who is deserving of care. Talk about death panels.
Look, I’ll say it again—I see the appeal of the free-market argument. It is beautifully and phlegmatically simple. Conservatives should make this argument because it is the only intellectually consistent argument against universal healthcare for all. Nay, conservatives must make this argument if they wish to oppose establishing healthcare as a basic human right. It’s easy to see why they’d rather not; they don’t want to be seen as the kind of raging assholes who would argue that Willis should be left to die in the road or that a single mom with cancer should be denied treatment, but they face a brutal conundrum: they want the system to function in precisely that way without ever having to argue that it should.
This is why people think the healthcare debate is so complicated. We’re pretending to have a debate about healthcare, but what we’re really doing is muddling through a smokescreen the GOP has deployed in the form of a faux debate about things that are fundamentally unrelated to health and care, namely, unpleasant features of the private health insurance market: deductibles, co-pays, premiums, pre-existing condition exclusions, continuous coverage requirements, denial of services, etc.—all of which are just a bunch of knobs and levers designed to ensure that insurance companies can make and grow profits off of our need for healthcare services. This is complicated, but it’s complicated by design.
Look, I am decidedly not arguing that insurance is bad. Insurance is an inherently socialistic scheme that I wholeheartedly approve of. It is nothing more or less than a way to pool risk so that when someone gets sick or injured, they don’t have to bear the full brunt of the costs. It’s kind of a perverse lottery; your premiums are the price of entry and those who hit the “jackpot” of illness or injury get a payout straight from the pockets of other people who weren’t lucky enough to “win.” That payout comes in the form of paid medical bills.
Let me elucidate this point by reframing a couple common complaints in lottery terms:
Complaint: “My premiums are too high!”
Translation: “These lottery tickets are too expensive.”
Response: Fine, drop out and pay cash for services.
Complaint: “My deductible is too high!”
Translation: “The taxes on my winnings are too high!”
Response: Too bad. It was all spelled out on paper before you bought your ticket. You had the choice to drop out and pay cash for services.
Yes, I know that Obamacare forced people to buy health insurance. I have two things to say about that. First, the penalty functions essentially as a tax to cover whatever we’re all going to have to pay for when you get sick or injured and can’t afford to pay your bills. It’s a nominal amount, especially if you make over $100,000 (roughly where the 2.5% of household income is capped).
Second, and more important, look at this:
Out-of-pocket healthcare costs were rising precipitously before Obamacare. Complaints about health insurance didn’t start in 2010 and they won’t stop if Obamacare is repealed. They also won’t stop if Obamacare is not repealed, because Obamacare is still a free-market system.
Back to my point: once you’ve signed onto the idea of health insurance as a good thing people should do, and if you’re not willing to let Willis die on the street, there is literally not a single good reason on the face of the earth not to a) put everyone in the same pool and b) stop letting a bunch of fat cats profit from our suffering. It’s not that that’s they’re doing so malevolently, necessarily. It’s just that for-profit health insurance is a casino—and in a casino, the house always wins. The house must win; shareholders must profit, executives must be paid exorbitant sums, the beast must be fed.
In a single-payer system, there are no such requirements. We all just pay the cost to run the lottery. Obviously, there are philosophical debates to be had about how such a system should operate—Should smokers pay more into the pool? Is birth control covered at the same level as Viagra? Does it make sense to spend hundreds of thousands on last-ditch, low efficacy treatment for terminal patients?—and so on. But those are honest debates about how to administer the pool equitably, about how to achieve the best possible health outcomes for the greatest number of people at the lowest cost.
I’ll take those debates every time over the casuistic garbage debate we’re having now between one side that views healthcare as a basic human right and one that won’t explicitly argue against healthcare as a basic human right but which also insists on the letting the market prevail, which is functionally the same as saying healthcare is not a basic human right.