Mitch McConnell’s decision to postpone a vote on his health-care-reform
bill, the Better Care Reconciliation Act of 2017, is a political setback
(and perhaps only a temporary one) for the Republican Party. But, beyond
this week’s drama, the bill and its troubles reflect conservatism’s
failure when it comes to thinking about health care.

Even if McConnell somehow manages to revive the bill in the coming weeks
and put together the fifty votes that he needs to get it through the
Senate, that broader failure will remain a problem for him and his
party. If they end up passing this bill or something like it, they will
be betting their future on a reform that cannot deliver what Donald
Trump promised during the election campaign and what Paul Ryan and his
colleagues promised last December: reasonably priced access to health
care for every American. Over time, political pressure would mount for
the restoration of Obamacare, or even for a public option available to
everyone.

Conservative supporters of the Senate bill disagree, of course. Writing
in the Washington Post over the weekend, Avik Roy, a former
health-care adviser to Mitt Romney,
said that passing this legislation would “represent the greatest policy
achievement by a Republican Congress in generations.” It would create “a
thriving, consumer-driven individual insurance market, with as many as
30 million participants, available to the healthy and the sick and the
young and the old, whose successes will lay the groundwork for future
efforts at entitlement reform.”

The Congressional Budget Office’s
analysis of the Senate bill, which was released on Monday, offered a very
different picture. If the bill were signed into law, the C.B.O. said,
tens of millions of Americans would eventually be added to the ranks of
the uninsured. Many others would face higher premiums, deductibles, and
out-of-pocket limits. Older and poorer people, in particular, would find
it harder to pay for health care.

Here’s an example plucked from a table at the back of the C.B.O. report:
Under the Senate bill, a typical sixty-four-year-old person who earns
$26,500 a year would see his or her insurance premiums leap from $1,700
to $6,500. In addition, this person could well see his or her annual
deductible jump sharply, from about $3,500 to $6,000.

In Ryan’s view of the world, people in this position would still have
“access” to health insurance. If they chose not to take advantage of it,
that would be their “choice.” But, of course, it is simply unrealistic
to expect people earning $26,500 a year to spend $12,500 on health care,
unless they are seriously ill. Among people aged fifty to sixty-four who
earn less than $30,000 a year, “the share without insurance coverage
would more than double from about twelve per cent to twenty-six per
cent," William Galston, a centrist Democrat who served in the Clinton
Administration,
noted on Tuesday, in the Wall Street Journal.

This is just one example of the Senate bill’s shortcomings, but the
problem is a general one. Far from providing universal coverage,
McConnell’s reformed insurance market would take the country back to a
system where the availability of health care is dependent on an
individual’s ability to pay. That, after all, is what markets do.

If you are serious about providing universal health care but you also
insist on maintaining the private-insurance model—as most conservatives
do—the only realistic way to deal with the problem is to direct public
money at it: give people of modest means generous subsidies to help them
buy policies, and give “cost-sharing” payments to health insurers so
that they don’t hike up co-payments and deductibles too much. Such
measures are insufficient, though. You also need to find a way to make
younger, healthy people enroll, to make the risk pools broad enough. And,
for those too poor to buy even heavily subsidized coverage, you need to
provide an ultra-low-cost public option.

The Affordable Care Act did all these things, and it still
encountered problems. Over all, it was a big success: between 2010 and
2017, the share of Americans under the age of sixty-five without health
insurance fell from roughly eighteen per cent to roughly ten per cent,
according to C.B.O. figures. However, the public option—the expansion of
Medicaid—accounted for about two-thirds of this decline. The
private-insurance exchanges, even with all the carrots and sticks that
the government employed, didn’t attract as many people as anticipated.
In some parts of the country, insurers have pulled out of the
private-insurance exchanges, competition has declined, and premiums have
risen sharply.

But, instead of building on the gains of the A.C.A. and attempting to fix
its problems, the bill proposed by McConnell would make things worse.
Over-all federal spending on health care would drop by $1.02 trillion
dollars over ten years. Although the bill would still offer tax credits
to low- and middle-income people for the purchase of insurance, these
credits would, in general, be less generous than those available under
the current law, and the income cutoff for financial-aid eligibility would be lower.

The biggest spending cuts would be applied to the most successful part
of the 2010 reform: the expansion of Medicaid, which would be gradually
reversed. Relative to the current policy baseline, the
public-health-care program would lose seven hundred and seventy billion
dollars. Consequently, according to the C.B.O., if the Senate bill were
to pass, fifteen million fewer people would have coverage under Medicaid
by 2026, and practically all of them would be low-income people.

It’s not just a matter of the Republicans looking to make budget cuts,
although for a party dedicated to the goal of cutting taxes, especially
for high earners, that is clearly an important part of the story. By
abolishing the individual mandate, the Senate bill would encourage many
young and healthy people to skip getting coverage. Almost immediately, according
to the C.B.O., the number of uninsured would rise by fifteen million—a
jump of almost sixty per cent. Over time, lower enrollment rates would
create all sorts of other problems.

The conservative counter-narrative is that, by stripping away
regulations, encouraging competition between insurers, and empowering
consumers, the bill would unleash the magic of the market. A fast-food
worker earning fifteen thousand dollars per year who lost access to the
Medicaid plan he enrolled in a couple of years ago could buy a private
plan, taking advantage of the government tax credits in order to set his
monthly premium around three or four hundred dollars.

But, for someone who makes $1,250 a month, before payroll taxes and other
deductions, three or four hundred dollars is a huge amount to pay out,
especially if it is going toward an insurance policy that comes with an
annual deductible of $5,000 or $6,000. Like the sixty-four-year-old in
the earlier example, the fast-food worker would surely “choose” to
remain uninsured.

In reality, of course, the only party here that is really exercising
choice is the Republican Party, which is refusing to accept the
principle of genuine universal access to health care—a principle that
virtually every other developed nation in the world recognizes. Until
the Republicans and their conservative backers surmount their objections
to this principle, they will be obliged to try and foist upon the
country policies that can only do harm to many of their own supporters.
After the July 4th break, they will doubtless hurry back to this task.