Opinion: The unspoken crux of the health-care debate

Seven years after the passage of the Affordable Care Act (ACA) and more than six months after the election of a repeal-and-replace majority in Washington, the health care quarrel remains unresolved. And now it’s leaking into Montana’s special congressional election.

Here’s why. Most Montanans believe in universal health care; many of them don’t want to admit it, though, and most don’t realize that they’re already paying for it.

Let me explain.

Folks on the left advocate universal health care. They’ve done so since well before Rob Quist’s 2017 congressional campaign. The position is easy enough to understand: access to health care is best—and at lowest cost—provided universally. Think of libraries, roads and parks, fire and police departments: call them public goods defrayed by public funds.

For folks on the right, folks like Greg Gianforte, health care has always been a private good, best provided—and competitively priced—by the market. Think of customers (who are patients) who purchase products (an appendectomy, for example) from providers (clinics and hospitals, nurses and physicians).

Customers of means receive their products on demand and pay their providers in cash. The less affluent are wary of the cash-and-carry risks; they maintain health insurance that kicks in as-and-when. ACA alters this equation only by making health insurance more affordable.

The Republican alternative to the ACA, the American Health Care Act, which has passed the U.S. House and faces an uncertain future in the Senate, would alter this equation again, mainly by making health insurance less affordable.

But there is a Third Customer. Folks in this category (a) can’t afford the cash-and-carry strategy, and (b) can’t afford or don’t qualify for or haven’t bothered to buy health insurance. Sooner or later, of course, an automobile accident or diabetes or stage-four cancer lands them in a hospital’s emergency ward.

There they receive care, often of the too-little-too-late variety. The costs are nevertheless considerable. And they are defrayed by the hospital and passed on to Customers One and Two in the form of higher prices for services rendered. Which, of course, is how most Montanans pay for the universal health care that they don’t believe in.

Listening to the health-care debate, you get the impression that it’s about the ACA, with universal care folks on the left, and the AHCA, repeal-and-replace, marketplace folks on the right. Actually, the ruckus is about the Third Customers. On the left is the conviction that universal care should—and would—take care of them; on the right is the conviction that it wouldn’t—and shouldn’t.

But then, too, on the right is the confession that accident victims and stage-four cancer sufferers mustn’t be left to die in the streets or in their beds. While on the left is the conviction that marketplace strategies, played to their logical conclusion, dictate exactly that.

Forget the debate between Obamacare and repeal-or-replace. The Third Customer is the unsolved piece of the puzzle. In the remaining days of the congressional campaign, folks should ask Greg Gianforte and Rob Quist whether they’re thinking about the Third Customer.

Bruce A. Lohof is a native of Montana. A former professor and a retired diplomat, he lives in Vienna and in Red Lodge.

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