The GOP's Healthcare Dilemma

If I were working for a 2012 Republican presidential aspirant, I’d be preparing now for this debate question: "Governor/Senator: Do you believe that the federal government should ensure that all Americans can buy an affordable health-insurance policy?"

It’s a tough question. If you answer "no" — well you are putting yourself pretty clearly on the wrong side of public opinion.

Americans may be divided on the Democrats' recent health reform. They don't like taking money out of Medicare; they don’t like the idea of the government making health decisions for them. (I know those two positions sound inconsistent, but hey: I'm reporting, not judging.)

But on the specific question I just asked, the American public expresses itself more than 70 percent in favor, according to the Kaiser Family Foundation. In a survey conducted during the George W. Bush years, The New York Times tested Americans’ generosity. What if helping the less advantaged increased the cost of your own health insurance? Forty-eight percent were still in favor of a government plan; only 38 percent said they were not. What if the plan added $500 to your tax bill? Forty-nine percent were in favor, 44 percent said "no," with independents polling slightly higher in the direction of "yes."

In other words, candidly shrugging off the uninsured will rub many voting Americans very much the wrong way. On the other hand, answering affirmatively carries other risks for a Republican.

Once you commit to covering everyone, you have taken a big step toward something that looks very like the plan Mitt Romney signed into law in Massachusetts.

There are infinite possible variations on that program, but it gets kind of hard to avoid its basic shape: regulation to define what insurers must cover, a mandate on individuals to buy insurance, subsidies for those who cannot afford insurance. It’s hard to escape the Romney-care destination — a destination mistrusted and disliked by the Republican Party's voting base.

Of course, you can omit the mandate — but then you need more subsidies, as people will wait until they get sick to buy insurance.

You can skimp on the subsidies — but skimping induces insurers to offer barebones policies that fail, for example, to cover certain items, such as mental health.

Or you can go light on the regulations, in which case insurers may be induced to offer those same barebones policies while pocketing the subsidies.

There are other possible solutions too of course, but they come with their own tradeoffs. To date, the default Republican position has been to answer the question with a tacit "no:'' accepting as inevitable a large — and rising — number of uninsured, but never disavowing an ultimate government obligation to provide care to those who need it.

The trouble with that position, as Romney himself used to argue, is that we're not a harsh-enough society to live up to it. We are willing to allow people to go without insurance. We are not willing to allow them to go without care. Result: They get care — but very late, and often at unnecessarily enormous cost and with unnecessarily poor results. For lack of $300 in insured prenatal care, we spend $300,000 in charity emergency care to rescue a premature baby.

So why not build our policy on what we are actually going to do? Answer the question "yes:" everybody should have insurance. Don’t be the party that wants to take coverage away. Be the party that makes coverage work better.

Originally published in The Week.