Many conservatives believe that a large proportion of Americans do not deserve access to medical care because their high medical costs result from poor decisions. This belief has been floating around right-wing circles for years. It resurfaced during the debate over the passage of Obamacare, was recently endorsed by Representative Mo Brooks, and again last week by Mick Mulvaney, the Trump administration’s budget director. Mulvaney defended the Republican health-care plan because it allegedly provides a “safety net” for people who “get cancer.” However, he insisted, “That doesn’t mean we should take care of the person who sits at home, eats poorly, and gets diabetes.”
Almost anybody who is not an American conservative would consider the premise that denial of medical care is a fair punishment for unhealthy behavior self-evidently monstrous. But since the idea has important resonance within the Republican Party — Mulvaney alone is a highly influential member of the Trump administration — it is worth examining the idea on its own terms.
There is some proportion of medical costs attributable to lifestyle decisions within one’s control. The Affordable Care Act does allow insurers to charge higher rates to smokers, but it doesn’t let them charge higher rates to people who eat badly, refuse to exercise, and so on. It is true that universal health insurance does subsidize the cost of unhealthy behavior. Let’s assume that we accept the premise that denial of medical care is a morally acceptable tool to attack this problem. (Which, to be clear, I very much reject.) Can the Republican health-care plan be justified as a response to this kind of moral hazard? No, it can’t.
The first problem is that the Republican health-care plan has no mechanism to sort the deserving sick from the undeserving. It simply uses the blunt tools of slashing hundreds of billions of dollars in subsidies to help people afford insurance, plus waivers for states to encourage insurers to medically underwrite their customers. Reducing subsidies, especially for older and low-income people, is not going to single out those who have made bad choices. It’s singling them out by age and income to make their insurance unaffordable.
Nor will the waivers to let insurers charge higher prices to people with different medical needs have such an effect. Insurers aren’t in the business of rewarding virtue. Yes, in an unregulated market, they would like to sign up healthy people with lower costs by offering them lower rates. But the insurers don’t care which expensive medical conditions are the result of sloth and which are the result of genetics. They want to avoid getting saddled with expensive customers of any kind.
It’s notable that, when Republicans need to come up with an example of a costly “essential benefit” mandated by Obamacare, their favorite one is maternity care. It is certainly true that eliminating coverage for childbirth would reduce costs for people who aren’t women of childbearing age, while raising costs for those who are. But having a baby is not a slothful lifestyle choice. It’s a medical cost that should either be borne by society as a whole (as Democrats prefer) or by the mothers alone (as Republicans do). Again, maternity benefits aren’t an example I am cherry-picking to make the GOP policy look bad. It is Republicans’ own favorite case of a way they plan to make insurance cheaper for non-mothers.
Suppose, however, that it would be possible to design some kind of plan to separate out insurance costs arising from bad decisions from those arising from bad luck, and the GOP somehow redesigned its plan so that it did impose all its coverage reductions on the lazy and unvirtuous. What evidence do they have that this massive human experiment would work at all? Does universal health insurance actually encourage unhealthy behavior?
Before Obamacare, the United States had the highest obesity rate of any OECD country, and was also the only one without universal health insurance. Within the United States, too, red states (which have the least generous Medicaid provisions and the highest uninsured rates) also tend to have the highest obesity rates. The United States has spent decades testing Mulvaney’s hypothesis that affordable medical care makes people shun healthy food and exercise, and is proving the opposite.
The indictment of America as a nation of gluttonous couch potatoes, while perhaps overstated, is not entirely wrong. Americans as a rule drive everywhere and eat a lot of junk. The irony is that this stereotype has always had cultural resonance with the cosmopolitan Europhile elite. The conservative populists are the ones defiantly hoisting massive vats of sugary soda and writing books with titles like God, Guns, Grits, and Gravy. (Three of those four things are associated with poor health outcomes.) They are the party opposing bike paths as a statist plot and hailing car dependency as the cornerstone of American culture. Donald Trump is the president who believes exercise is bad for you because it drains the body’s fixed and finite energy supply. He has abruptly reversed the Obama-era cultural symbolism celebrating activity and vegetables, instead broadcasting his love of junk food and addiction to television.
Unsurprisingly, the Republican health-care plan would disproportionately harm Trump’s own voters. There is no starker example of the clash between the GOP’s cultural politics and the practical impact of its economic agenda.