Republicans, for once, are sounding downright squeamish about onrushing massive cuts to Obamacare subsidies, with premiums on the exchanges expected to more than double on average starting next year. GOP House committee chairs are reportedly having some “brainstorming sessions” about what to do, and House Speaker Mike Johnson claims that they will “be rolling out some of those ideas” at some point.
So far, the genius idea in the lead is Trump’s pitch to reroute subsidies from health insurance companies to the American people, so they can buy health care. (House Republicans have already filed a bill that looks like this.) When asked whether people wouldn’t then just use that money to buy health insurance, Trump replied, “Ahh … some may. I mean, they’ll be negotiating prices.” Congratulations, folks, you now get to be your own private dealmaker with the health care system, and with your purchasing power and risk pool of one household, I’m sure you’ll get the best price!
The stupidity is the point. For decades now, the Republican Party has been dedicated to the proposition that rich people are too highly taxed and the working and middle classes get too many benefits from the government. With the passage of the One Big Beautiful Bill, they have finally caught the car. Medicaid and Obamacare have been slashed to free up budget headroom for tax cuts heavily slanted to the wealthy. Republicans don’t have a “health care plan” per se because this is their plan: to take your health care funding and give it to Elon Musk, Donald Trump, and the rest of the fascist billionaire class.
American conservatism is a strange political beast. Like all conservatisms across the world, it stands in defense of hierarchy and privilege, but it is welded clumsily to 19th-century orthodox capitalism. By this view, all income should come from working or owning property, and all goods and services should be obtained through the market. It would be unjust for anyone to receive a welfare benefit from the government, because they did not work to earn it. This is a philosophical problem for conservatism, as George Scialabba writes, because capitalism regularly and wildly disrupts the established social order as technologies and businesses evolve. (For the record, this view is also very stupid.)
But it’s a much more practical problem for a Republican trying to write a health care policy. Health insurance is straightforwardly impossible to square with capitalist morality for reasons a child can understand. Most obviously, people routinely get very sick or injured through no fault of their own, and require care that is far more expensive than they can afford out of pocket. Sometimes people have chronic conditions that cost many multiples of what they could ever possibly earn. Therefore, unlike the market for car or home insurance, where each person is charged exactly what they are statistically expected to claim (plus a margin of profit), any functioning health insurance scheme must have systematic transfers from the young and healthy to the elderly and sick.
With a pure market approach, only the very rich will be able to get all the health care they need. Even people making well into six figures will not be able to afford elaborate surgery or cutting-edge therapies out of pocket. The poor—or really anyone living paycheck to paycheck—will not get health care at all. Before Obamacare, that was the reality for many, with the only “insurance” available on the market being de facto worthless if you ever actually needed it.
This is what led early socialists and social democrats to advocate for national health insurance, run by the government. If the market is a fundamentally stupid way to pay for medical treatment, then throw everyone onto the same program, and fund it out of taxes. That way, the risk pool and the funding base will be as large as possible, people will be charged based on their ability to pay, and all citizens will be permanently insured. And historically, the fact that both the elderly and the poor were largely uninsured up through the early 1960s was a major motivation for the creation of Medicare and Medicaid.
Republicans have hated Medicare and Medicaid since the moment they were proposed, because they’re welfare programs. Ronald Reagan got his start in politics with an unhinged mini-documentary claiming Medicare would lead to a totalitarian dictatorship. Historically, Medicare has been too politically secure to touch—at least for now—but Republicans finally took a trillion-dollar bite out of Medicaid in the One Big Beautiful Bill.
Now, it is possible to set up a health insurance system based on markets: It’s called the Obamacare exchanges. All you have to do is set up an elaborate system of regulations to prevent the market from doing the thing it normally does, namely ration health care by price. You provide subsidies so people can afford premiums, and then forbid insurers from discriminating against sick people (guaranteed issue), or creaming off the healthy people (community rating), plus many, many other regulations. It’s basically a highly inefficient pantomime, but it does sort of work if it’s funded and regulated properly.
But Republicans hate this too. That’s why they voted dozens of times to repeal Obamacare, and why they shut down the government and illegally halted SNAP benefits rather than agree to Democrats’ demands to extend the enhanced Obamacare subsidies that were finally set at a high enough level to make the system affordable.
Their replacement “ideas” consist of either shifting the subsidies to people, who will then find out that they’ll have to use the money to buy health insurance. As some Freedom Caucus members recently floated, that could translate into pre-Obamacare fake insurance, which does nothing for people when care is actually needed.
It’s not impossible for conservatives to have a semi-workable health care policy. In many European countries, conservative parties emerged from a tradition of church and king, and are not so wedded to capitalist morality. It was the German arch-reactionary Otto von Bismarck, for instance, who set up Europe’s first national health insurance scheme, in an attempt to steal a march on the German socialists and win some support from the working class. The German corporatist welfare system as it subsequently evolved is worse than the Nordics’, but it’s better than America’s.
Absent a philosophical revolution that is nowhere in evidence, however, American conservatives will never have a health care plan worthy of the name. There is no way to improve the system without some combination of regulations, subsidies, or expansion of public programs. Rather than grappling with that obvious fact, and embracing Obamacare as the most ideologically palatable option on offer—or moving toward some Herrenvolk-style whites-only health care—under Trump the party has doubled down on Reaganite tax and welfare cuts that will gravely harm their own voters. A handful of vulnerable Republican members of Congress might be bullied into supporting Obamacare subsidies, but that’s about it.
If Americans want better, cheaper health care, they should not vote for the party of mindless cruelty and destruction for its own sake.
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Ryan Cooper is the Prospect’s managing editor, and author of How Are You Going to Pay for That?: Smart Answers to the Dumbest Question in Politics. He was previously a national correspondent for The Week. His work has also appeared in The Nation, The New Republic, and Current Affairs.
