The debate over Ryancare has opened a window into the divergent souls of Democrats and Republicans.
A look through that window reveals that their competing positions on health care are animated by fundamental differences in what they value, and how they perceive the role of government.
Democrats believe that the power of government should be used to improve peoples lives.
Republicans believe that the power of government should be used to create an even playing field. Governments role is to provide opportunity. Armed with that opportunity, people are free to improve their lives or not, as they see fit.
Sure, Democrats believe in opportunity. And Republicans believe that improving peoples lives is a good thing. And everybody believes in mom, apple pie, and Tom Hanks.
But this is a battle over which values will win out over others to shape the direction of our nation. And over the meaning of freedom.
This is a battle over which values will win out over others to shape the direction of our nation. And over the meaning of ‘freedom.’
The Republican Party has pretty much appropriated the word freedom. There is even a so-called Freedom Caucus in the House of Representatives. The Freedom Caucus is a group of highly conservative Republicans who essentially interpret freedom to mean freedom from government interference in the daily lives of Americans.
For Republicans, freedom is literal and hard-edged. No squishy freedom from want or freedom from care for them. Freedom means you get to do what you want to do, for good or ill. Not to commit crimes, of course, but pretty much anything short of that.
The Republicans view of freedom is baked into their proposed legislation to begin the process of repealing Obamacare, the American Health Care Act. Lets just call it Ryancare for now.
Ryancare is a complex piece of proposed legislation, but Im going to focus on one key provision that lies at the heart of it, the elimination of Obamacares so-called Individual Mandate.
The Obamacare Individual Mandate requires most people to have health insurance. If they dont obtain coverage that meets certain minimum standards, they have to pay a penalty.
The Mandate is essential to the underlying goal of Obamacare to provide affordable coverage to as many people as possible. A major obstacle to reaching that goal is the high cost of covering older, higher risk people, and people with preexisting medical conditions. If Obamacare was going to require insurers to cover more of these high-risk people, the cost of doing so had to be mitigated.
The Individual Mandate was designed to do that. By bringing large numbers of younger, healthier people into the insurance pool, the Individual Mandate spread the risk to a bigger group and made coverage more affordable for those at higher risk.
In essence, the young healthy people in the insurance pool subsidize the older, less healthy people because they require less medical care.
But those in the younger and healthier column are also getting something in return. They are obtaining insurance coverage that they otherwise might not have had. After all, even normally healthy people can get sick or injured, and its a dangerous game to play the odds by leaving themselves uninsured.
The rest of us also benefit by having more people covered. We no longer have to pay for as much health care to be delivered at high cost in the emergency room.
When Republicans look at the Individual Mandate, they dont see a mechanism to make coverage more affordable for more people. They see Big Brother. To them, the Individual Mandate is an unwarranted government intrusion. Eliminating it promotes freedom.
Getting rid of the Individual Mandate means that people will be free to buy insurance or not, without the government penalizing them for their choice.
Republican freedom includes freedom to be uninsured.
For Democrats, eliminating the Individual Mandate eviscerates what they consider to be the fundamental right to affordable health care. The remaining insurance pool would be smaller, older and less healthy. For many of those remaining in the pool, the cost of coverage would be prohibitive.
Nothing could illustrate the divide between Democrats and Republicans more clearly than their respective responses to the Congressional Budget Office report that scored the proposed Ryancare legislation.
The CBO report estimates that over the next ten years, 24 million fewer Americans will have health insurance under Ryancare. The report also predicts that Ryancare will reduce the federal deficit by $337 billion over the same period.
Both sides criticize the CBO report on the margins, and the Republicans go so far as to attempt to undermine the credibility of the CBO as a neutral umpire. But neither side has mounted a serious, credible attack on the core findings of the report.
Sure, Republicans can quibble with the CBOs estimate that 24 million people will lose coverage under Ryancare. But whether it turns out to be 24 million or only half that number, Republicans arent seriously arguing that a lot of people wont lose coverage.
And Democrats can disagree with the CBO report about how much the federal deficit would be reduced by Ryancare. But they dont, and cant, dispute that moving from Obamacare to Ryancare would reduce the deficit, at least to some extent.
The CBO report has become a political Rorschach test. Show the report to different people, and they see different things that reveal more about themselves than about the report.
Paul Ryan sees the report as vindication for Ryancare. I think if you read this entire report, Im pretty encouraged by it, and it actually exceeded my expectations.
Ryan turns the lemon of lost coverage for millions of Americans into freedom lemonade. Governments not going to force people to buy something they dont want to buy. Once the individual mandate is gone, guess what, people are not going to buy that. And for Ryan, thats a good thing.
In other words, Ryan doesnt dispute that his bill will leave millions of people without coverage. But hes not troubled by it. To the contrary, hes encouraged by it because it gives people more freedom.
No matter that the freedom in question is freedom to be uninsured. So long as people have access to insurance, the argument goes, it really doesnt matter whether they have coverage. If they dont convert their access to coverage, thats their problem. Government should stay out of it.
Thats the Republican freedom agenda in action.
Democrats see an entirely different picture when they look at the CBO report. They view the millions who will lose their coverage as proof that Ryancare breaks faith with the American people. Ryancare diminishes the fundamental right to affordable health care, and fails to live up to governments obligation to extend that right to as many people as possible.
In other words, this is not a debate about facts as much as it is a clash of values.
Democrats and Republicans dont just have different opinions on Ryancare, they express them by drawing from different vocabularies. Democrats talk about how many people will lose coverage. Republicans talk about access. Democrats invoke the values of decency and moral obligation. Republicans talk about freedom.
And this is just the beginning of the debate. The current Ryancare proposal is just Step One in what Republicans are promising will be a three-step process to complete the task of repealing and replacing Obamacare.
We dont yet know whether Ryancare, or anything like it, will be enacted into law, much less exactly what it will look like if it is.
But we do know that at the end of the day, what we get will depend on who wins the competition over values, not the squabble over numbers.
Philip Rotner is an attorney and an engaged citizen who has spent over 40 years practicing law. His views are his own and do not reflect the views of any organization with which he has been associated. Follow Philip on Twitter at @PhilipRotner