Several commentators have suggested that Conservatives are against the Affordable Care Act (ACA) because they are afraid that it might work and in doing so disprove their small government philosophy. But this misses the point – It is how the government would make it work that worries small government Conservatives.
Right now the United States spends more on healthcare than any country in the world, about 18% of our gross domestic product. By comparison European countries average about 12%. Despite our higher spending not all citizens in the U.S. have healthcare coverage – about 15% of Americans have no healthcare insurance. Many people blame private insurance companies for our expensive healthcare system, but insurers actually have very little to do with rising costs. Instead it is technology, utilization and lifestyle. Medical technology companies are coming up with more ways to fix problems we used to have to live with, and more expensive procedures to replace older, less expensive procedures. People are using more of these services – things we used to live with now we expect to be able to get fixed. And our lifestyles are costing money as well – people not taking care of themselves has led to an increase in adult onset diabetes, high blood pressure and a range of other expensive, chronic maladies.
None of these issues are directly addressed by the Affordable Care Act – instead it focuses on providing funding mechanisms (mostly more government money) to extend healthcare coverage to the people that don’t have it. If all the Affordable Care Act achieves is to increase coverage at the same cost per person, it will achieve one goal, providing universal coverage, but come close to bankrupting our country – we cannot afford to spend 21% of our GDP on healthcare. So the only way the Affordable Care Act can actually work is by rationing – somewhere, somebody in government will have to make a decision on what to pay for, and how much extra to charge people for the cost of their own irresponsibility.
Rationing is something that all healthcare systems do (and a primary reason why European countries spend less on healthcare). In the United States we have made it very hard for private insurers to ration care. Despite periodic stories of insurers refusing to pay for specific treatments, there are thousands of pages of state and federal laws that obligate insurers to pay for a wide range of treatments and technologies and limit insurers’ ability to charge irresponsible people higher rates. On top of this, it is very easy to sue an insurer that denies a claim. By law and by tort system, we have made it almost impossible for private insurers to effectively ration care.
The federal government doesn’t have these same restrictions. It is very difficult, and in many cases not even possible, to sue the Federal Government. Further, the Federal Government isn’t usually bound by state laws and often exempts itself from laws that apply to private companies. In combination this allows the Federal Government to much more effectively decide how to ration healthcare. The Federal Government can arbitrarily decide what it will cover and not, and is effectively beyond challenge.
So if the Federal Government succeeds in controlling healthcare costs where private insurers could not, it won’t happen because of some inherent advantage of big government over the private sector – it will happen because the government is allowed to do things that private insurers aren’t allowed to do. The Federal Government will be able to do the rationing that the private sector can’t.
And at a very deep philosophic level, the government making these rationing decisions is unsettling for small government Conservatives – it means putting the government in charge of deciding who lives and who dies. Small government Conservatives know that big government can effectively ration, and there are many examples throughout history of big governments deciding which of their citizens live and die. But they would prefer the United States not become one of those countries.
The Affordable Care Act is the law of the land and needs to be implemented – this is how democracy works. Hopefully, once implemented, it will create a groundswell of concern that will lead to the ACA being changed and improved – this is also how democracy works. But the concerns of small government Conservatives about the direction of the law and its impact on the future of the Unites States are valid.