Did Medical Darwinism Doom the GOP Health Plan?

“We are now contemplating, Heaven save the mark, a bill that would tax the well for the benefit of the ill.”

Although the quote reads like it could be part of the Republican repeal-and-replace assault against the Affordable Care Act (ACA), it’s actually from a 1949 editorial in The New York State Journal of Medicine denouncing health insurance itself.

Indeed, the attacks on the ACA seem to have revived a survival-of-the-fittest attitude most of us thought had vanished in America long ago. Yet, again and again, there it was in plain sight, as when House Speaker Paul Ryan (R-WI) declared: “The idea of Obamacare is that the people who are healthy pay for the people who are sick.” Contemporary language, but the same thinking that sank President Harry Truman’s health care plan almost seven decades ago.

Ryan’s indignation highlighted a fundamental divergence in attitudes that repeatedly turned the health care debate into a clash over the philosophy behind Obamacare-style health insurance. To some, the communal pooling of financial risk of medical expenses seems too often an unacceptable risk to personal responsibility.

As a researcher who has documented this approach to health care, I’ve been startled to see the debate over the AHCA reignite a political philosophy and policy approach that seemed to be have been discredited – and be in sharp decline.

When Truman launched the first comprehensive effort to cover all Americans, most of the population had no health insurance.

Last year, thanks to the ACA, nearly 90 percent did, according to a Gallup-Healthways poll. Yet then and now, many conservatives have downplayed the impact on physical health and focused, instead, on fiscal temptation.
If you can’t afford to be sick, then don’t be

Take, for instance, Rep. Jason Chaffetz (R-UT) warning low-income Americans on March 7, 2017 that they had “to make a choice” about their spending: “So rather than getting that new iPhone that they just love and want to go spend hundreds of dollars on that, maybe they should invest in their own health care.” (He later walked back his statement.)

In reality, of course, the premiums from the GOP’s late and abandoned American Health Care Act would dwarf any savings from iPhone abstinence. For a 64-year-old making US$26,500 a year, the cost of health insurance would have shot up from $1,700 to $14,600, according to the Congressional Budget Office (CBO), or more than half that individual’s pre-tax income.

Chaffetz and others seem to sincerely believe that “what keeps the great majority of people well is the fact that they can’t afford to be ill” – although those words come from the 1949 editorialist again, not a Trump administration tweet. The editorial continued:

That is a harsh, stern dictum and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor? That in order to get their money’s worth they should be sick at every available opportunity? They will find out in time that the services they think they get for nothing – but which the whole people of the United States would pay for – are also worth nothing.

As it happens, the effect predicted in 1949 on the detection of cancer – less of it – is precisely what has happened with the spread of high-deductible health plans praised by conservatives for encouraging more careful “shopping” by “consumers.” A study in Medical Care showed that screening rates for colorectal cancer declined under high-deductible plans until, under Obamacare, the federal government forced those plans to include first-dollar coverage of preventive services. The screening rates for colorectal cancer promptly rose. A recent study in Cancer found the same results for mammography.

Separately, surveys and research on high-deductible plans have found that 20 to 25 percent of people have avoided needed care of all kinds because they can’t afford it.

Nonetheless, the GOP’s conservative wing denounced ACA-mandated “essential health benefits,” echoing the idea that it is a threat to American freedom. Or as that same New York medical journal put it:

It is time that someone – everyone – should hoist Mr. Charles Darwin from his grave and blow life into his ashes so that they could proclaim again to the world his tough but practical doctrine of survival of the fittest…The Declaration of Independence said that man was entitled to the “pursuit of happiness.” Any man who wishes to pursue happiness had better be able to stand on his own feet. He will not be successful if he feels that he can afford to be ill.

The quality of mercy is not strained

For most physicians, that compassionless condescension lies in the faraway past; for example, the AHCA was overwhelmingly opposed by medical professional groups, including the American Medical Association.

Yet an implacable medical Darwinism retains a firm grip on many conservatives, even on physicians. Then-Oklahoma Sen. Tom Coburn, an obstetrician/gynecologist and prominent Republican, told a sobbing woman at a 2009 public meeting on the ACA that “government is not the answer” when she said she couldn’t afford care for her brain-injured husband.

Similarly, in 2011, after the ACA passed, then-Rep. Ron Paul (R-TX), also an obstetrician/gynecologist, was asked what should be done about an uninsured, 30-year-old man in a coma. “What he should do is whatever he wants to do and assume responsibility for himself,” Paul responded, adding, “That’s what freedom is all about, taking your own risk.”

Or as conservative scholar Michael Strain put it in a 2015 Washington Post editorial: “In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals – including…less government coercion and more individual liberty.”

Strain is right, of course, that resources are limited. Moreover, it’s long been known that overgenerous health insurance can lead to overuse of medical care services.

However, most Americans, including some prominent conservative intellectuals, don’t see stripping away health insurance from 24 million countrymen – the CBO’s estimate of the AHCA’s 10-year impact – as striking a blow for liberty. In a Quinnipiac University poll released just before the scheduled AHCA vote, only 17 percent of respondents approved of the Republican plan and 46 percent said they’d be less likely to vote for someone who supported it.

One day later, GOP leaders withdrew the legislation, sparing Republican representatives a vote “on the record.” Although Vice President Mike Pence has called evolution an unproven theory, it turns out Republicans really do believe in “survival of the fittest” (at least in a political sense), after all.

Michael Millenson is an author, consultant and contributing editor for THCB. This post first appeared in the Conversation.


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9 replies »

  1. By the way, health insurance does mean health coverage, Anish. If you have auto insurance, it means your car is “covered” by insurance. That’s not a political point, it’s an English-language reality. If what you mean is conflating health insurance with access to health care services, there is, of course, a connection. The literature I cite on high-deductible plans and much other literature shows that.

    Meanwhile, a great debating point is to change the subject. I am not defending every aspect of the ACA. I am saying that those pushing the AHCA were absolutely heartless and disconnected from the reality of everyday life. Even Avik Roy cringed at their impact on the poor (he is linked to). The problems of today’s system are not due to the ACA; it has made some worse and some better. Fixing it requires a sense of social solidarity. Physicians like those below who don’t like the ACA are, first and foremost, physicians. Bravo to Anish and the others for your caring on a personal and policy level. Let’s start from there.

  2. Medicaid rates wouldn’t be the new norm because that’s not a price point that doctors can deliver care at. I realize the ultimate central planner plan is to replaced the PCP with NP’s – which may be able to survive at that lower price point, though.

    The ACA certainly helped some people – I think I’ve said that. I flatly disagree with your imagination of what drove policies in the AHCA The vast majority of proposals I’ve seen and certainly the one’s that I mentioned – EHB, age band, restricting enrollment windows – were intended not to screw poor and sick people , but to create healthier risk pools.

  3. Nice job Anish… right on. Your frustration is with trying to get Mike or Steve or Jeff, or any of these guys to stop whining is in vain. They won’t say it, but they ONLY want socialized medicine. End of story. There is no fixing it. They have no solution other than that or at least I don’t hear any solutions, just constant complaining. Until they get what they want. I say let NY, CA, WA, have socialized medicine and leave it up to the states then, so all of these Utopian believing folks can go live in those states where they get their holy grail, government healthcare for all.

    The only priority for anyone writing about how evil the republicans just want everyone to die in the street is exhausting. They act like not only do they not care about people, they WANT them to die, its ridiculous.

    But it can be really funny if your smart and see it for what it is. I’d like to see more solutions from the left or I’d just like to see their socialized medicine plan so we can get to the real debate. But it’s hard to come up with a solution when you don’t believe there is a problem. We’ll all be gone by the time this has to get paid for, so why worry? Why aren’t the democrats coming up with something to fix ACA?

  4. Suppose the free market approach to health care works. That means that Medicaid rates would be the new norm. Why would it be so much better that we get there via the market vs Medicaid?

    No, the last question is a real one. So many people are claiming that pre-ACA health care was better, or that the ACA made things worse. I simply want to make sure I understand your claims correctly since you seem to fall into that group. Do you really think patients were better off before the ACA or, the converse, worse off now?

    “but it certainly isn’t true for the majority of (for instance) small practice doctors ”

    Agreed, but they aren’t writing health care policy or writing about it. If they were doing health care policy I don’t think this is an issue, however they are not. Like it or not philosophy/ideology influences what people put into policy. I read pretty widely and participate in a long term email chat group with mostly conservatives and libertarians in it. This kind of thinking has clearly resurfaced. “If you are sick it is probably your fault, so I am not paying for it.” As I said, there is a bit of truth to it so policy should address it, i.e. sometimes people really are at fault for their own problems, but when this is the primary driver this is not good.

    Yes, Meaningful Use was stupid, but then I lived through managed care, so government bureaucrats don’t have a monopoly.


  5. The main plank on the left – mostly from folks who don’t run practices – seems to be expand medicaid. That was a large chunk of how ACA expansion expanded coverage (14/20 million).. It varies from state to state, but in general medicaid has price points that make it very hard to not lose money – everyone who has to balance the books at the end of the month knows this – See niran’s last post about the mayo ceo’s entreaty to slow play medicaid patients. (As an aside, seema verma understood this and diverted tobacco tax dollars to up medicaid rates in Indiana).

    Separate from the coverage expansion, the ACA, through meaningful use, sought to put a heavy imprint on practice workflow. I love the efficiency of EMR’s and would have had one anyway – but using it in the manner the central planners envisioned with meaningful use – was to put it kindly, idiotic.

    I’m not avoiding the point in Michael’s post. He is falsely charging that there is some new ethos among conservatives that suggests that the sick should have to pay for themselves. Again, he brings political ideology into a conversation that doesn’t really need to exist. I’m sure that point may be true for some, but it certainly isn’t true for the majority of (for instance) small practice doctors (who arent necessarily all conservative) I talk to. Most want as many people to have good access to healthcare as possible. Our point would be that the current mechanism of delivering care to as many as possible fails miserably because the unit cost of health care is too high. Single govt payer is certainly one solution, but certainly not the only one.

    To cast the AHCA as a put it on the sick is not the intent – its how liberals/left wonks dress it up to politicize things and create divisions. The age band, essential health benefits, reducing windows of enrollment were policies intended to lower the cost of premiums. We can debate whether they would have succeeded – but the lazy argument is to fit this to the ‘conservatives want the poor to die’ narrative.

    Your last paragraph is the usual shtick that is so tiresome. Yes I’m a physician – but I have the ability to advocate for myself and my patients. The nurse sitting next to me right now has a bronze obamacare plan with a $3000 deductible. He hasn’t seen a doctor since he signed up for a plan because its too expensive. So yes, i’m glad he’s covered against a catastrophe happening.. but me asking for this system to be changed doesn’t suddenly make me a survival of the fittest darwinist – or a conservative for that matter. All that arguments at this level do is keep people in their respective bunkers so we can lob ideological grenades at each other.

  6. Since some of us don’t do primary care, it would be helpful if you could actually describe how things are really different now than they were before ACA. In particular separating out things that were already trending in a certain direction, but now get blamed on the ACA, like physicians no longer owning their own practices.

    Also, to be fair to Michael, you avoid the point of his post. There is no avoiding the fact that many conservatives appear to want to place the burden of the costs of illness upon those who need the health care. This works OK if you are healthy or relatively well off, but given that most health care dollars go to chronic care or large expenditures, it just won’t work for many, probably most people. The common rejoinder from the conservatives is that if we just unleash the free market, magic will happen and costs will be so low everyone could then afford all health care. However, when you look around the rest of the world where there is first world health care, it is still pretty expensive. So if you look at someplace like Singapore which has nearly ideal conditions to control costs, that uses some market methods but also uses government controls and is essentially just a big city, or even the NHS and consider those places as the world record holders, there is a real floor on costs.

    Finally, Michael, in my estimation, tiptoes around the re-emergence of blaming the sick as a core part of conservative belief. It has always been there, and heaven knows there is some truth to it, but letting that belief come to the forefront and guide all health care policy is toxic.

    Query- Health insurance is not health coverage. You think things are worse now for you as a physician. What about those patients who died or had major morbidities for lack of insurance which meant they couldn’t get coverage/care before the ACA was in effect? Were they really better off but just didn’t know it?


  7. Michael unfortunately does the usual – conflating health insurance with health coverage. Michael if you think what we have now is so incredible – go ahead and open up a practice and operate under the current system. Prove me and Niran wrong. I have never been a republican, and don’t quite understand why health policy is so politicized. I want as many people as possible to have access to health care, I want everyone to have access to basic coverage to pay for catastrophic events (pay 4 that however you like). What I don’t want is a system that transfers large sums of money to middlemen, who then dribble it out in 25-40 dollar per visit drips to the hapless primary care physician. Does that make me a medical darwinist??

  8. Keep fantasizing and keep changing the context of what the opposition actually said.

    I don’t like Ryan either, but I try and keep my statements about him factual.