Medical Darwinism Has Pervaded Recent ACA Debate

GOP May Question Evolution, But it Seems to Embrace Survival of The Fittest
By Michael Millenson

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,(R-WI) declared: “The idea of Obamacare is that the people who are healthy pay for the people who are sick.”

Ryan’s indignation highlighted a fundamental divergence in attitudes that repeatedly turned the healthcare 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 healthcare, 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 President Harry 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% 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.

Take, for instance, Rep. Jason Chaffetz, R-Utah, 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.”

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.

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.

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.

Separately, surveys and research on high-deductible plans have found that 20% to 25% 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.

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-Texas, 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.”

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% of respondents approved of the Republican plan and 46% 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 and consultant. A version of this article originally appeared at the Conversation blog.