Re-redistributeThe ideology behind Republicans’ health-care bill

REPUBLICANS presented their efforts to overhaul the Affordable Care Act, which flopped this week, as a necessary response to a failing law. They frequently say the individual market, in which those who do not get health insurance through their employers can buy it for themselves, is collapsing. Premiums rose by an average of 22% in 2017. So many insurers have given up on the market that about a third of counties have only one left; 38 are at risk of having no insurer for 2018, according to the Kaiser Family Foundation, a think-tank. Yet the Republican bill is not a technocratic fix for these problems. Rather, it is an attempt to enforce conservative thinking on health care. And it is failing partly because of ideological faultlines in the party.

To see this, start with the fact that the bill makes the individual market weaker, not stronger. It abolishes the individual mandate—the requirement that everyone who can afford insurance must buy it—and makes subsidies for low- and middle-income buyers less generous. The Congressional Budget Office (CBO) forecast that the first version of the Senate’s bill would have reduced enrolment in the individual market in 2018 by over a third—a more dramatic collapse than anything seen to date.

Next, consider the changes to the bill made by Senator Ted Cruz of Texas. His “Consumer Freedom Option” would allow insurers to sell almost completely deregulated plans, so long as they continue to offer some that followed Obamacare’s rules. This is an attack on the redistribution inherent in the law. By forcing all plans to cover certain things—such as treatment for mental health—Obamacare ensures that those who fall victim to such conditions, or who already have them, pay the same for insurance as everybody else. Their medical costs are spread around.

Mr Cruz sees this as an unwarranted incursion into consumers’ freedom of choice. His amendment would lead many healthy people to buy cheap plans covering little. If they then contracted a condition which their plan did not cover, they would have to wait six months before returning to the Obamacare exchange. Because the exchange would contain mostly sickly people, premiums would rocket. The plan is akin to allowing consumers to buy cheaper cars without seat belts, with the added side-effect of pushing the price of cars that keep them much higher.

Some redistribution would live on. Poor buyers would still have their premiums capped. And the bill stumps up $182bn over a decade which states could use to subsidise the exchanges. But this vexes purists. Rand Paul, one of the four senators who is standing in the way of the bill’s progress, describes it as a “giant insurance bail-out superfund”.

The problem is that conservatives are divided over whether the government has any business at all in health-care markets. All agree that Obamacare’s high premiums are a problem. They fall on a small number of buyers who earn too much to qualify for their subsidies. Many of them are self-employed and therefore part of a key Republican constituency. The 155m Americans who get insurance from their employers do not have to bear the same costs. But the question is: who should? The right of the party’s answer is that the sick people must pay for themselves. Mr Paul says health care is a “market item” that should not be subsidised. But most Republican plans, like the Senate bill, steer some taxpayer cash towards the 20% of Americans who incur 82% of health costs.

Changes to redistribution in the individual market are somewhat hidden. But the bill’s cuts to Medicaid, health insurance for the poor, are in plain sight. The CBO thinks they would leave 15m fewer people enrolled in Medicaid than would be under the current law by 2026. Republicans find these cuts hard to defend, often denying they exist. Susan Collins, another Republican rebel in the Senate, thinks they are too deep—the polar opposite of Mr Paul’s objection. Most Americans worry about increased government spending but nevertheless think the government should ensure everyone has health insurance. Republicans are divided and confused over the extent to which they agree.