‘I Don’t Think Policy Has to Be Binary’
Avik Roy began writing about health policy when Congress—and the rest of the country—was debating the Affordable Care Act. “I would be reading various people online and not finding anything I really agreed with,” he says.
He felt liberals were presenting the good things the ACA would do while glossing over the potential pitfalls he was worried about. But conservatives were focusing on ideology, calling the ACA “an expansion of the welfare state” and “a violation of constitutional principles” instead of discussing how specific provisions would affect health care and health coverage, he says.
“Nobody was really writing what I wanted to read about the ACA,” he says. “I had to effectively create it myself, so I started a blog, which was the cool thing to do back then.” At the time, Roy was a medical school graduate who had handled health care and biotech investments at Bain Capital and JP Morgan Chase. He says the only one reading the blog at first was the mother of an ex-girlfriend.
Now, Roy is the opinion editor at Forbes, manages the Forbes healthcare policy blog The Apothecary, and is co-founder and president of the nonpartisan think tank the Foundation for Research on Equal Opportunity.
He advised Mitt Romney’s presidential campaign in 2012, and Rick Perry and Marco Rubio’s respective campaigns in the 2016 primary. In the latter two campaigns, the candidates adopted Roy’s proposal to reform the Affordable Care Act in a way he says could achieve universal coverage.
Roy will discuss that plan in a Public Health Forum titled “The Conservative Case for Universal Coverage” on April 18.
Ahead of the event, Roy sat down to talk about his vision for universal coverage, how Republicans can reform Obamacare instead of repeal it, and why they aren’t doing so.
What is the basic conservative case for universal coverage?
Traditionally, the idea of universal coverage has been associated with the left, so much so that there are people on the right who believe that achieving universal coverage is or would be a triumph for the left and something that ought to be opposed.
I have been arguing for many years that conservatives are gravely mistaken in opposing the cause of universal coverage. The goal to ensure that every American has financial security and good health insurance is a goal worth achieving, and there have been many leading free market thinkers over the years who supported that goal, including Friedrich Hayek and Ronald Reagan and many others. There are ways to achieve universal coverage that deploy more market-oriented, consumer-driven approaches.
Also, if you are a conservative who is concerned about the fact that we have $47 trillion in unfunded liabilities mostly driven by federal healthcare programs, then you should want to reform the healthcare system in a way that ensures that more people can afford health insurance.
What does “market-oriented, consumer-driven” universal coverage look like?
Switzerland and a number of other countries around the world have achieved universal coverage with systems in which consumers have a lot more choice in terms of the type of insurance they obtain, private or public, and also where they get their healthcare, in private hospitals or public hospitals, private clinics or public clinics.
In my view, and the view of most free market types, the ACA exchanges are over-regulated and the insurance products sold on the exchanges are too expensive. But in general, the model of subsidizing health insurance for those who cannot afford it was the right one.
We should liberalize the exchanges so people have more choices and premiums are lower, and expand that system into other populations where people want more choice in their insurance plans. Instead of getting insurance from our employers, why shouldn’t people who work also shop for their own coverage? Why shouldn’t people who are on Medicaid not be integrated into that system? People who are 64 can buy insurance on the exchanges, so why can’t people who are 65?
This is basically what the Swiss do, and it works pretty well. We can adapt the Swiss model to our system, and actually save money and cover more people. Is that not what we all want?
How does this vision compare to the current focus on “repeal and replace”?
The Republican mindset about repeal and replace is flawed, because it tends to take the pre-Obamacare status quo as implicitly the ideal system—or at least a system that was really good—and say that Obamacare, per se, is a problem. That is not true. The system we had in 2009 was failing people for all the reasons that are certainly well-understood by the advocates of the Affordable Care Act.
Why is that the Republican mindset?
One reason is purely ideology and party politics. You have a health reform plan that expands the role of government, and it was passed by a Democratic president and Democratic members of Congress in a party line vote. You’re not going to like that as a Republican.
There is another issue that is talked about less. The ACA was a fiscal transfer from people who benefited from the pre-ACA status quo to people who were uninsured. In the pre-ACA status quo ante we spent, in today’s dollars, $800 billion a year on Medicare and another $400-plus billion a year through the tax code subsidizing employer-sponsored insurance. A lot of the vocal Republicans and Republican voters who think that the healthcare system was just fine pre-ACA were people who were effectively, maybe even unbeknownst to them, heavily subsidized by the pre-ACA system, and continue to be subsidized today.
Seen in that light, you can see that if you over-generalize, a lot of Republican voters look at the ACA and say, “Something was taken away from me to give something to people who I assume are Democratic voters.”
You put all that together, and that is driving a lot of the Republican feeling about the ACA in a direction that doesn’t always lead to the ideal approach to policy.
Why did you found the Foundation for Research on Equal Opportunity after the 2016 Republican primary?
I grew increasingly troubled by the nativist streak, shall we say, in Republican and conservative circles. I saw a negative approach to politics coming out of a segment of the pro-Trump base that I thought was problematic.
I am someone who believes that free markets have proven to be the best tool we have ever invented to lift people out of poverty around the world, yet conservatives tend not to talk about what markets can do for people, how they can lift people out of poverty, how they can expand opportunity. Conservatives talk about it in terms of, “Leave me alone. We should be faithful to the Constitution,” which I don’t think are attractive arguments to people who aren’t already conservative. If you want to be a movement or a political party that is truly national instead of tribal, then you need to show how your ideas are going to make everybody better off, not just the people in your tribe.
Our goal at the Foundation for Research on Equal Opportunity is to see if we can come up with ideas that actually achieve the goals of both progressives and conservatives at the same time. Just like my argument on health care was that we can achieve a traditional progressive goal of universal coverage by adapting certain conservative ideas around consumer choice and market innovation, we could do the same thing in other sectors of the economy and other areas of public policy.
I don’t think that policy has to be binary, that one side wins and the other side loses. If you find ideas that both progressives and conservatives can genuinely embrace as achieving their goals, then just maybe there is an opportunity to rise above the polarization that we have endured for the last nine years.