Republicans pressing for repeal and replacement of the Affordable Care Act are stressing one broad theme over and over: Freedom of choice.
The House GOP bill, called the "American Health Care Act" and now moving through Congress, aims to free up health insurers from what conservatives see as oppressive regulations that they say drive prices up, push insurers out of the market, and leave consumers with higher costs and fewer choices.
“We're not going to make an American do what they don't want to do," House Speaker Paul Ryan said Sunday.
"What we're trying to achieve here is bringing down the cost of care, bringing down the cost of insurance not through government mandates and monopolies but by having more choice and competition," Ryan added.
“The AHCA places trust in the decisions of individuals and families by making greater use of health savings accounts ... and respecting their ability to follow incentives to be continuously insured,” Douglas Holtz-Eakin, president of the right-leaning American Action Forum and former director of the Congressional Budget Office, wrote in a commentary for the Washington Post.
But long before Obamacare was in the works, health policy experts on both the left and the right looked at the issue of freedom of choice. They decided having too many choices was a bad thing -- especially if one of those choices is to go without health insurance altogether.
Health insurance is difficult to understand. And pre-Obamacare, some companies sold people bare-bones policies that looked cheap up front, with low premiums, but that saddled customers with high deductibles, co-pays and caps on coverage once people started getting sick.
"Insurance is not really the end goal here"
That’s why Obamacare has a list of essential services, why it requires insurance companies to cover anyone who applies, and why it forbids them to dump undesirable customers.
In return, health insurance companies demanded a mandate or some other mechanism that made sure that more people bought health insurance — especially younger, healthier people who would pay in but not claim much back.
Polls show people like that aspect of the ACA, even if they don’t like rising premiums. But the answer to higher premiums is not cutting back on coverage, medical groups argue.
“Freedom to choose junk insurance has nothing to do with getting the care we need,” said RoseAnn DeMoro, executive director of the National Nurses United union.
She says that’s what Ryan's bill threatens to do.
“In fact, it is the false choice of a faux freedom," she added. "This bill lets insurance shape what procedures doctors do, what drugs we take, and even which doctors we can see.”
And before Republicans were against that mandate, they were for it.
The battle over health reform has been going on for decades. In 1989, economist Stuart Butler wrote a blueprint for reform at the Heritage Foundation, a bastion of conservative thinking. Called “A National Health System for America,” one section is titled: “Mandate all households to obtain adequate insurance.”
Butler, who has since moved to the nonpartisan Brookings Institution and who switched his thinking on the mandate, compared health insurance to auto insurance.
“If a young man wrecks his Porsche and has not had the foresight to obtain insurance, we may commiserate but society feels no obligation to repair his car,” he wrote in the blueprint. “But health care is different. If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance.”
That’s the problem with letting people choose not to have health insurance if they don’t want it, said David Cutler, an economics professor and health policy expert at Harvard University.
“One way or another, sick people cost money,” Cutler said.
Treating heart attack victims in the emergency room is far more costly than preventing the heart attack with good medical care.
“The best thing that we can do to protect health is to prevent illness in the first place,” said Dr. Leana Wen, Baltimore’s health commissioner. “The emergency room is not the safety net. By the time that people get there, it’s often too late.”
A patient with schizophrenia may cost $50,000 a year to treat, but left untreated, could end up in jail at the taxpayer’s expense, Cutler said.
“You can say, ‘I want to pay for them through taxes’. You can say, ‘I want them to die because they don’t deserve coverage’. But you can’t say, ‘I don’t want to pay for them but I want them to get care,'” he added.
The new GOP plan seeks to encourage — but not mandate — people to get insurance by letting companies charge higher premiums for those who have gone without coverage.
"Insurance is not really the end goal here," White House Office of Management and Budget Director Mick Mulvaney told MSNBC.
And it also would let states decide what kind of policies insurance companies should offer.
DeMoro, of the nurses union, sees it as a recipe for disaster.
The Obama administration even had trouble controlling insurers who sought to trim what they offered, she said.
“Even through the ACA, health exchanges, insurers routinely change plan designs yearly in ways to increase out-of-pocket costs and limit patient choice through narrower networks,” she said.
That was one of the biggest complaints about Obamacare — some customers lost access to doctors and hospitals they'd been using for years.
Cutler also worries people will try to game the system if they don’t have to buy high-quality insurance.
“They can say, ‘I am going to buy a crappy health insurance policy because I know if I get really sick someone will take care of me,'” he argued.
Holtz-Eakin doesn’t think that’s a risk.
“It’s never been the case that we’ve had a race to the bottom with health insurance,” he said. “That’s not my model of how markets behave…Insurers offer policies that people want to buy.”