The GOP Health Bill Promises “Access” And “Choice.” Don’t Believe It.

With their proposal to “repeal and replace” the Affordable Care Act, Republicans are proposing to take away subsidized health care insurance – and more than a trillion dollars in benefits – from 24 million people in the middle class and poor over the next decade and redistribute over 80% of the proceeds to the rich through tax cuts. But the Republicans have put a fine veneer over this “reverse Robin Hood” swindle – they argue that Americans will enjoy both better “access” and “freedom of choice” – when the reality is that they will have neither, in any meaningful way.

The GOP’s promises have all the hallmarks of a classic con, which typically includes three steps: (1) An effort to confuse and mislead the “mark,” in this case, the poor and middle class; (2) Winning the mark’s alliance against an imaginary third party, in this case, “big government”; and then (3) Taking their money.

The heart of the con is conservatives’ conflation of “access” and “freedom of choice.” Conservatives imply that freedom of choice includes access, when in truth these are two very different things, particularly when it comes to health care.

“Freedom of choice” means no one is forcing you to choose one option over another. “Access” means you actually have some options open to you, including the means to exercise your choice. Meaningful freedom requires some of both—options and choice. If you have the money to purchase a bunch of attractive options, but are forbidden the freedom to buy any of them, the claim of “access” to those options becomes meaningless. Similarly, if you have complete freedom of choice, but no money to purchase any of the attractive options, your claim to “freedom of choice” as to how to spend your money is meaningless. To label either extreme—choice without options, or options without choice—as a precious “freedom” is a cruel trick.

It’s especially cruel in the context of health care, where (with the notable exception of abortion before Roe v. Wade) there’s always been unrestricted freedom of choice. In the private market health care system, there are literally thousands of doctors and hospitals vying to provide you with whatever treatments you want.  Access to health care is a different matter than choice. Access means you actually have the ability – i.e. the money – to get the care you desire.

The law is called the Affordable Care Act because Democrats recognized that affordability is the make-or-break issue for access. The ACA made health care affordable to the poor and middle class through subsidies funded by increased taxes on the wealthy. Without it, as the Congressional Budget Office analysis showed, they wouldn’t have access, except through charity—which has worse health care outcomes.

To divert the “marks” from looking further into who would benefit and who would be hurt in a “replacement” bill, Republicans have for the past seven years moved to the second classic step of a confidence game: winning the alliance of the mark against an imaginary third party. In this case, the imaginary third party is an evil “big government,” which wants to enslave you, and prevent you from enjoying the good “free market,” which gives you freedom and prosperity.

The most sophisticated and genteel basis of this “great freedom con” was developed by libertarian hero F.A. Hayek. And his case is, ironically, based on “access” and “choice.” Hayek made a sharp distinction between negative and positive freedom. Negative liberty is freedom from constraints or coercion—the freedom of choice—and positive freedom is the ability to get what you want—access. Hayek argued that state power is coercive, since the state through its policing powers has a monopoly on legitimate use of violence. Buying and selling in the private market—including of your own labor—he said represents only free choice and a positive benefit to the society. To get maximum freedom, then, government should be restricted as much as possible to protecting life and private property. Once you try to have the state involved in promoting positive freedoms—access to things people desire—government will insist on controlling people’s choices, causing an inevitable slide downhill to The Road to Serfdom—the title of Hayek’s classic and hugely influential 1944 book.

Because Hayek viewed any positive government action to help people as leading to enslavement, Hayek disapproved of President Franklin Delano Roosevelt’s “freedom from want” as a direct goal of government action. But in reality, the slippery slope which Hayek wrote about in 1944 never happened, nor were the social forces there for it to happen. FDR’s Social Security was able to provide access to old age insurance, without depriving people of liberty.

In fact, social insurance programs, such as Social Security and Medicare, have never led to breakdown of the rule of law, nor the denial of fundamental rights, nor have they impeded the functioning of the private sector. On the contrary, they have helped the private sector thrive. Indeed, every rich country has social insurance programs, and all, with the exception of ours, have universal health care coverage—some since the late 19th century. And nobody has been enslaved by these. To take one example, tax revenues made up nearly 50% of Denmark’s gross domestic product (GDP) in 2014, in contrast  to 26% of GDP here in the United States.Yet Denmark was rated higher in 2016 than the U.S. by the World Bank on both press freedom and ease of doing business.

The idea of a big government that could enslave you through welfare programs gained traction during the war on communism, when conservatives conflated the Marxist-Leninist advocacy of total governmental control of the economy with government-organized social insurance programs intended to serve as a safety net for citizens and complement the private sector.

In fact, communism been such a good bogey man that Republicans have never stopped conflating social insurance with communism. For example, in 1961, Ronald Reagan warned that if we instituted Medicare, “one of these days you and I are going to spend our sunset years telling our children, and our children’s children, what it once was like in America when men were free.” Well, it’s 56 years later, with over 50 years of Medicare; the children’s children are adults, Reagan is gone, and we’re still free.

The great freedom con, though successful for decades, may well be crumbling. First, when people are confronted with the very real threat of losing an existing benefit (health care), they are less likely to worry about an imaginary threat (big government). Second, though they can repeal Obamacare, the Republicans can’t repeal arithmetic.

Universal health insurance is inevitably very complex, but the bottom line arithmetic is still stubbornly simple. Modern health care is at historically high levels of both effectiveness and expense. And if we don’t use tax revenues to subsidize the poor and much of the middle class, they won’t be able to afford it. This was confirmed again by the Congressional Budget Office, which did the arithmetic, again. It found that 14 million people would lose health care coverage next year alone under the Republican plan, as a result of the cuts in subsidies. Republicans have managed to keep up the con on the ACA for nearly seven years, voting repeatedly to repeal the bill and even winning re-election on never-delivered promises to provide a much better replacement system. Now their time may be up.

William Berkson

William Berkson is a Philosopher and Director of the Jewish Institute for Youth and Family. He did his PhD in Philosophy under the late Sir Karl Popper, author of The Open Society and Its Enemies. He is the author of Fields of Force (Routledge), Learning from Error (Open Court) and Pirke Avot: Timeless Wisdom for Modern Life (Jewish Pub. Soc.).