There is a famous thought experiment called the trolley problem, and it goes like this: A runaway trolley is headed toward five people bound on the tracks. You are standing before the switch that could divert it onto another track, where it would kill only one person. Do you pull the switch?
The problem is a way of grappling with the moral responsibility of actively killing a person for some larger end, a problem that lurks behind much of the role of the state, from policing to Harry Truman dropping the atomic bomb on Japan. The trolley problem is the most flattering possible way to think about the conservative movement’s fanatical commitment to repealing Obamacare. That is, if you ignore the obvious elements of partisan spite, callousness, and self-deception, one can posit a commitment to abstract moral principles about the role of the state. Conservatives’ abstract principles, like most people’s, can come attached to specific costs. If they pull the switch and repeal Obamacare, or if they persuade five Republican Supreme Court justices to cripple it, they will spare America from the evils of mandates, taxes, regulation, and what they imagine to be European socialist horrors. They will also kill what are now identifiable human beings.
One of those human beings is David Tedrow, who, in a harrowing first-person account published in the Washington Post, writes of his fight with non-alcoholic cirrhosis, crediting Obamacare with saving his life. “Without insurance and the subsidy I would simply die,” writes Tedrow, “because I could not afford my drugs and my body would reject my liver.”
Last night I linked to the story on Twitter, writing, “The Republican Party is trying to kill this man.” The description was slightly hyperbolic in the sense that killing Tedrow is not the Republican Party’s goal — they would be perfectly happy if, after they have repealed Obamacare, a generous philanthropist stepped in to save Tedrow’s life — but rather the direct and inescapable result of their behavior. He is collateral damage in the service of a larger goal, like the populations of Hiroshima and Nagasaki, or the imaginary stranger on the railroad track.
My tweet set off a backlash so furious it was catalogued by Twitchy, which is the inadvertently apt name for a right-wing aggregator of reflexively hostile Twitter reactions. The fascinating thing about the response was its uniform, fervent denial of the possibility that crippling or repealing Obamacare would have the effect Tedrow describes. It is true that Tedrow’s previous insurance was canceled in the fall of 2013, when new regulations phased out many previous plans. But it is also true, as he explains, that his previous insurance was unaffordable, and that pre-Obamacare insurance plans were routinely canceled. The individual insurance market before 2014 was dominated by adverse selection, which is an incentive for insurance companies to shed expensive customers.
The fundamental problem is that, for millions of Americans, the cost of medical care exceeds what they can afford, either because their incomes are low or because their medical expenses are high, or both. Government can give them affordable insurance by spending money directly, though this violates the conservative commitment to never raising taxes for any purpose. Government can also make insurance available to sick people by preventing insurance companies from charging market prices to sick customers, though these regulations, which result in higher prices for young and healthy customers, also turn out to offend conservatives. This is why the Republican health care program expressed through a series of repeal votes, budgetary frameworks, and innovative legal challenges, all involve restoring the pre-Obamacare status quo.
What makes the conservative denial of Tedrow’s story so bizarre is how utterly banal the story is. You can find plenty of examples of people who, if not for Obamacare, would not be able to afford necessary medical care. Such stories feature heavily in Jonathan Cohn’s masterful book about the health care system. One can also see this demonstrated in the aggregate in Massachusetts, where a state-level version of Obamacare produced a drop in the mortality rate.
That it is dangerous and potentially fatal to lack health insurance is hardly an exotic or complex theory. People generally understand this.
The fact that repealing Obamacare will kill some people does not settle the question of whether Obamacare is better than some imaginary alternative Republican health-care plan, or even whether it is better than the pre-reform status quo. Conservatives are within their rights to prefer freedom from taxes and regulation even at the cost of David Tedrow’s well being. But any morally serious position has to account for the brutal realities embedded in this trade-off. Truman’s war strategy involved killing a lot of Japanese civilians. The Republican health-care strategy is to flip a switch whose immediate effect will be to impoverish and kill a lot of people. Is there a single conservative who will admit this?