Sometimes, I am gobsmacked when I watch conservatives talk to each other. Take, for example, Kevin Williamson of the National Review trying to explain why Republicans should examine some European health care systems. Basically, this is a reaction to the increasing popularity of Medicare-for-All or similar single-payer systems among Democrats and Democratic office-seekers. For Williamson, a lot of liberals are clueless and don’t understand that Europe has a variety of approaches to providing health care and that most of them don’t resemble the “national-monopoly provision on the British-Canadian model.” In other words, maybe we can have a European system after all, and maybe Republicans should begin exploring a new approach.
But once he begins describing the situation, he quickly gets to the nub of the problem. What Americans seem to want is a system of private insurance that is regulated to ensure that everyone is covered, even if they are horrible insurance risks. Since you can’t compel private companies to operate at a loss, this necessitates a “complex regime of mandates, regulation, and subsidies.” In other words, what people want is something exactly like the Affordable Care Act.
Here’s the thing: Republicans, and most Americans, say they want a system in which insurance companies are obliged to cover expenses associated with preexisting conditions. They also want insurance to be provided privately in the market. I have a very hard time seeing how you can have both of those things without having an individual mandate, without which the underlying incentives all but ensure a dysfunctional insurance market. You’d have no incentive to sign up for a plan and pay premiums until you came down with something expensive.
This is the Republicans’ dilemma: They hate the Affordable Care Act, but they want certain benefits (choice of private insurers, coverage of preexisting conditions) that more or less necessitate something like the basic structure of the ACA — which is to say, a necessarily complex regime of mandates, regulation, and subsidies.
Such systems are more the norm in much of the world than is the national-monopoly model. They have significant deficiencies of their own, and some strengths, too, which would be worth understanding as we proceed.
If the Republicans hadn’t demonized the Affordable Care Act, they could use it for their alternative model to what the many Democrats will be pushing for on the 2020 campaign trail. This shouldn’t surprise us. The Affordable Care Act was modeled on the Massachusetts health care law that was established while Mitt Romney was serving as governor of the Bay State. And the Massachusetts law was based on a 1993 plan the Heritage Foundation promoted (very disingenuously) as an alternative to HillaryCare. So, we’ve been here before.
The Republican dilemma is that they hate the only solution that would approximate what they actually want. They hate it because President Obama signed it into law. They hate it because they’ve lied about this law nonstop for more than a decade and those lies are very internalized.
The result is that they’ve boxed themselves out of the health care debate. They really want to be defending the Affordable Care Act or something nearly identical to it. They want to defend this kind of system because they very much prefer it to the “national-monopoly provision on the British-Canadian model.” But they can’t really defend the status quo because they told everyone that the status quo was a Marxist-Leninist takeover of the American economy.
The Democrats will defend the Affordable Care Act against attacks, but they won’t defend it for long against better alternatives. So, how do the Republicans position themselves? They can try proposing something like the Affordable Care Act and call it something else. Maybe introducing some Swiss or German elements would give them some cover to attempt this, although they’d still be proposing “European health care.”
Williamson comforts himself that the people, at least for now, still seem to prefer a system of private insurance. But if the Republicans can’t defend that kind of system because it requires the subsidies and regulations of ObamaCare, then they can’t advocate for what the people want.
That suggests to me that the consensus on health care will soon move to the left. In a tug-a-war, things don’t remain contested when one side lets go of the rope.
Well, Obamacare with Swiss elements would really be Obamacare on steroids. The Swiss system is much like the ACA except that the insurers are so tightly regulated that they all offer essentially identical products. Their only real role is administrative. It also covers everybody — no patchwork of Medicare, Medicaid and employer-provided insurance + subsidized and regulated individual policies. Out of pocket costs are fairly high but subsidized for the needy. So I doubt it would be more attractive to conservatives that the ACA.
This is the fundamental problem the Republicans have. Obamacare is the most right-wing health system of any developed country and probably the most right-wing one that could, more or less, work. The Republicans have spent a decade distorting and lying to claim that Obamacare is an epic disaster, totally unworkable, etc. This has created an enormous appetite for reforms – there would have been a fair amount anyway because it has its limitations, but now conservatives who “should” be defending it aren’t. Their problem is that any useful reform is going to move the healthcare system to the left and they don’t have a good way to resist reforms.
The problem with the Swiss model for the US is that the individual mandate in Switzerland is highly coercive. Insurance is mandatory like we require insurance to drive. Anybody who doesn’t have coverage can have their wages garnished to pay the reasonable premiums.
And the insurance industry is so highly regulated that they can’t deny coverage. Other countries have similar systems, and they work, but they require a degree of coercion (mandate) that is quite unpopular in the US.
That’s the key. What people want are premiums they can afford and drug prices they can afford.
Here in America, the only possible solution is a public option into expanded Medicare. Single payer will never gain enough political support to pass, due to the right wing attacks “you’ll lose your doctor! You’ll have to go to a government clinic!” Etc.
We should support single-payer anyway so that we can get the public option as a fall back. Then we will have to fight over funding mechanisms, because Republicans will try and starve Medicare and argue that “it’s too expensive.”
And any Republican president who wins will immediately try to cut back Medicare and Medicaid as a way to expand the private system.
I have been maintaining for some time that M4A may be some ultimate goal but a more realistic short-term goal would be the single payer option. This would help not only individuals without employer-provided insurance but also small businesses and non-profits that are struggling to cover their employees.
But Booman is right. The GOP’s hatred of Obama and actually regulation of the private sector in general in general no matter how good he and regulations provided has always backfired on them.
. . . would be the (im)plausible deniability that it was just revised Obamacare.
France combines single payer for the first 80 pct of costs and optional, regulated private insurance for the rest.
Which is, almost exactly, Medicare for All, since medicare also covers about 80% of costs and leaves beneficiaries on the hook for the rest.
Yup, I prefer the French system myself but our doctors wont since French doctors only make 100k a year.
Yes but medical school tuition is free.
Well, after I lost corporate health insurance I had to take a part-time job to cover health insurance costs; I can’t really say that the ACA did much to help a lot of us, so I won’t mourn when it’s replaced with something “for all.”
Was never THE solution, or even meant to be. We’re on Medicare with supplemental insurance, so it didn’t personally affect us, but I know many who got no insurance because even the ACA wasn’t affordable for them.
This is stretching the definition of “based on” way beyond the breaking point.
Thank you, marduk. It’s infuriating to hear liberals criticize the ACA by declaring it “the Heritage plan” or “a Republican plan.” As detailed at the links, the Heritage/Republican plan severely undermined the Medicaid program, while the ACA as originally written provided maximal expansion of Medicaid eligibility. It’s the best part of the Law, and too many liberals studiously ignore it.
It’s best when liberals who want to advocate for better health care policy have a good working knowledge of health care policy.
Haven’t hear repeal and replace in awhile. That’s progress.
“They can try proposing something like the Affordable Care Act and call it something else.”
If the GOP wasn’t so driven by and consumed with blind irrational hatred, the smart thing to do when Trump came in office would have been to just take the ACA, tinker around the edges, restore the good aspects of it they destroyed, rename it TrumpCare, declare victory and call it a day.
The only thing they know how to do is demonize. And they really don’t care about actually governing.
True words.
If they had taken their majorities and renamed it, and created a Medicare buy in to let’s say……..55, they would still have the House, they would control the Senate for a full generation, and Trump would have a 60% chance of being re-elected. They could have had everything else the ever wanted.
But in their world hate rules.
I think that is something Booman misses almost every time. The hate.
.
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“They hate it because President Obama signed it into law. They hate it because they’ve lied about this law nonstop for more than a decade and those lies are very internalized.”
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They hate it because it was signed into law by a black man. They hate it because a `too large’ (to them) percentage of its beneficiaries are black/brown people, all of whom they consider lazy, shiftless thugs. They REALLY hate it because paid health care is a non stop route to women having agency over their bodies. They absolutely hate it, forever and ever, because their hearts are nothing but hate and greed.
They will never support anything resembling it, ever…because it relieves just a little bit of stress in the daily living of the working poor, and can possibly leave a little more cash in the average working stiffs pockets, which breaks the basic principle of their financiers governing philosophy;
More cash for us.
Fuck you.
.
.
And besides they all have health care, soup to nuts.
“More Cash for Us
Fuck you”
.
But the point remains, this “logic” isn’t working for them. It results in a political problem …
We pay about twice as much per capita as the average health care bill of other developed countries. And we have worse outcomes. How in the world can you have less expensive health care when we use fhealth care insurers who pay taxes, chase profits and marketing costs and high executive salaries and monopolize drug costs. Check it out.
https:/www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries#item-sta
rt
The biggest driver in our insane costs is not the health insurers though. They don’t help because they don’t do a good job bargaining with providers, but it’s the providers that are the real international outliers. Hospitals, doctors & pharmaceutical companies.
Yes, and no one really negotiates with the providers. So they get to pile it on.
BTW, the idea that no one really negotiates with the providers is insane. In most markets there are a small number of giant insurers, and if you don’t accept their patients, you’re screwed. Plus, a huge number of patient are Medicare patients, and the government sets those rates (which insurers tend to track, BTW).
So, actually, providers have a lot less power than the insurers do. Monopsony is a much bigger issue in health care than monopoly.
This really isn’t the case. Look at the case of Zuckerberg Hospital and Trauma Center in San Francisco. It’s the only Trauma Center in the region, and it’s deliberately chosen to be out-of-network with ALL insurance companies. They have complete control over non-medicare pricing and they charge through the ying for it. And that’s in a wealthy, major metro region! Many areas have hospital groups owned by one umbrella company. My mid-sized city has a total of two provider entities despite having multiple hospitals in the area. Insurer’s ability to negotiate prices is much more limited than one would think.
I don’t think SFGH (aka Zuckerberg at least for now) is a good example. As a public hospital it turns no one away. The Department of Public Health’s Mission is to serve all people of SF but the focus is on the underserved. The biggest source of revenue by far is Medi-Cal. Accepting insurance companies would potentially crowd out and deny access to those it is there to serve and for them there is nowhere else to go. Charging “through the ying” is a way to offset the low payment rates of Medi-Cal, Medicare and Healthy SF. And even at that the Department receives $600M annually from the City’s general fund to balance the books.
It is the only trauma center in SF. It is the only option for anyone who needs emergency trauma care. Rich, poor, or in between, they have nowhere else to go. There would be no “crowding out” needy people. It would just prevent people who have insurance from being robbed.
So are we only talking about insurance for trauma patients?
Trauma patients are the patients that have little to no choice about where they end up. It’s obviously a much less serious problem if a hospital doesn’t accept insurance for non-emergency and elective care because the patient can be served elsewhere.
The patient can be served elsewhere, but guess who’s the biggest provider of private sector health care in San Francisco? Yep, Sutter Health.
Kaiser Permanente and Dignity Health, the other two dominant providers of hospital services in San Francisco, join Sutter in having their own physician foundations so they can all dominate non-emergency health clinic markets as well. All three private systems are frequently raising their prices for acute- and sub-acute care.
Meanwhile, the two largest providers of outpatient dialysis services in California, DaVita and Fresenius, operate 73% of the business in the State. They’re gouging the public particularly egregiously, with yearly profit margins three to five times the overall margins made by California’s hospitals.
Massive consolidation of health care provider markets are a big problem in most of the United States.
Zuckerberg San Francisco General Hospital engages in these billing practices with all their private pay patients, not just the trauma victims.
Zuckerberg/SFGH is a weird exception, and it’s only for trauma, not for anything else.
Look at most markets and you’ll find a couple of dominant insurers. Maybe just one! You have very limited bargaining power in such a circumstance. If you don’t take what they offer, you lose most of your business.
There is no place I’m America where providers run the show price-wise. None. If you think otherwise, you simply don’t understand health economics.
I wish I had been involved in this conversation when it was fresher, but I’m glad I found it now.
scottso, I concede that insurers have lots of market power, but your inferred claim that providers are not cost drivers is simply wrong. There has been terrific market consolidations from health providers in recent decades. State governments could and should have been more aggressive in preventing those market consolidations, but they were not, and here we are.
Please check out the factual claims in this lawsuit, “People of the State of California v. Sutter Health”, to see just one example of a health care provider which is using its massive market power in Northern California to shove around insurers and all other purchasers of health care in order to extract obscene prices for care services.
The State is asserting here that Sutter’s practices and pricing have become illegal, but I assure you that there are plenty of providers who are charging similarly obscene prices while managing to avoid criminality under our insufficient laws.
I encourage you to begin at page 4 of California’s lawsuit against Sutter Health to see a historical summary which is very responsive to your claim that health insurers clearly have more market power than health providers. This section of the lawsuit describes Sutter successfully fending off a legal challenge to one of their biggest hospital mergers in the year 2000 by making your essential argument. Sutter convinced the Court that they would not be able to violate antitrust laws because health insurers would have the market power to prevent Sutter from having maximum pricing .
control.
In its 2018 lawsuit, the State of California explains how Sutter used a combination of ever growing market power and an exceedingly aggressive set of business practices to cause abusive price increases in their consolidated markets, making the 2000 court ruling wrong in its assumptions.
Centerfield, thanks for bringing that case to my attention. I infer there hasn’t been a ruling yet?
Certainly there are some places like that. But in any case, for every one of those there are many more markets where there are one or two dominant insurers whom one can not afford to lose business from.
For example, take Pennsylvania, where I practice. Look at the share of the insurance market in the major metros here:
https:/www.markfarrah.com/mfa-briefs/a-brief-analysis-of-health-insurance-competition-and-commercia
l-market-share
As you can see, in Philly, Independence Blue Cross has nearly 60% of the market, and Aetna another third. 90% are with 2 insurers. As a provider, if you don’t take IBC patients, you’re fucked. So they have inordinate power to dictate reimbursement terms.
Look at Harrisburg: Blue Cross & Aetna have 40% each. They have huge power to tell you what they’re paying with a market like that.
U. Pitt Med Center attacked the problem creatively by starting their own insurance product. (That has its own conflicts and it’s a weird situation.)
But again, the idea that nobody negotiates with providers, or has the power to do so, is ludicrous. The Sutters are much more the exception than the norm.
Have there not been significant consolidations of health providers in the Philly metro area? I’m certain it hasn’t reached the level of consolidation which you are reporting here in the insurance market, but it doesn’t have to get to a commensurate percentage to be a problem.
For example, in the regions where Sutter Health is most dominant they have around 25% of the hospital bed capacity, but they’re plenty powerful enough to tell Anthem Blue Cross of California to take a hike unless they accept big price hikes which the insurer will then pass onto their premium payers. I expect that Sutter’s vulnerability makes it likely that the insurers are taking a stronger position in these negotiations, but there are lots of providers making massive margins on their patients with private insurance who are not being sued by California, providers who have the power to drive their own hard bargains.
It’s also worthwhile to know that the Affordable Care Act regulates health insurers in ways which it does not to to health providers.
Among the most significant of these is the Medical Loss Ratio, which limits the portion of premium dollars health insurers may spend on administration, marketing, and profits. This policy requires insurers to pay rebates to their customers if they spend too much money away from direct patient care.
Unfortunately, the ACA does nothing to regulate the way acute- and sub-acute health providers spend their revenue, and the Law also failed to take on any pharmaceutical pricing regulations at all, passing on the opportunity to use the Federal government’s purchasing power to shrink Big Pharma’s profiteering and increase Medicare’s long-term sustainability.
No, there has not been a ruling in the California v. Sutter case. The provider filed for dismissal of the charges, which doesn’t appear to have succeeded. I expect the two sides are negotiating and that Sutter will seek to settle.
Meanwhile, there has been an initial trial date set for this June for “UFCW & EMPLOYERS BENEFIT TRUST V. SUTTER HEALTH”, a class action suit filed by a major Union in California which runs its own trust to finance health insurance plans for its members. The basic claims by the plaintiff here are similar to the State’s filing, that Sutter has established the power to force health insurers to accept anti-competitive terms.
scottso, I believe you and centerfielddj, in your excellent discussion, are speaking at cross-purposes on one point: the definition of “provider”. The providers centerfielddj is speaking of appear to be the mega-provider hospitals; you appear to be speaking from the perspective of an individual care provider — a physician, nurse practitioner, etc. — an individual who indeed would have little or no market power (even if organized into a consortium of physicians) against either insurers or hospitals.
The lone physician pretty much has to accept the insurers’ reimbursement terms, get approved into their HMO or other provider network(s), get accreditation from the dominant hospital corporation(s) in his/her practice region, to survive.
So I may be misinterpreting your arguments, but my perception is that you are both right within your particular definitions of “provider”.
Yet another example of how complex the whole health care topic is.
. . . nailed it down and put it into words.
This is wrong. Administrative overhead is a YUUUUUGE contributor to high American health care costs, and that’s all on the insurers. Plus profits.
Physicians’ fees make up a small part of total health care costs. The VAST majority is hospital charges. Drugs are next.
Also, don’t forget the fact that physicians in the US have to spend hundreds of thousands of dollars to go to school, and then have loans to pay back. In other countries medical education is paid for. You literally can’t pay US doctors what you pay doctors in other countries because the economics don’t work and nobody in America could ever afford to go to medical school. You’d have to make med school free.
Frankly, BS. The ACA limited insurance overhead to 20% of fees. Mandatory rebates if they exceed that limit. Our total cost is not merely 20% higher than the international standard.
Sorry, still wrong.
How much administrative time has to be put in by hospitals and providers because of insurer’s requirements?? From chart reviews to prior authorizations to appeals of denials to forms… there are personnel on the OTHER side who have to do all that, not just the insurer’s side. Hospitals, practices, pharmacies, nursing homes… everybody has this gigantic administrative burden because of insurers. It’s not just the 20% on their end.
Your ignorance of the operation of the health care system is showing.
How ludicrous. You blame provider administrative inefficiency on insurers?
I’m going to guess you’re a doctor?
Following up on this:
Total administrative overhead is 8%. While not ideal this obviously doesn’t even begin to account for the spending discrepancy between the US and peer nations. This is clearly consistent with the points I’ve made.
It doesn’t appear to be my ignorance at issue here.
Once again, you’ve missed my point.
This is the formal cost of administration on the insurers’ end. But how much of what providers have to charge on THAT end is because of the immense number of hours that have to be put in due to administrative tasks??
Answer: A FUCK-TON
Source:
https://www.nytimes.com/2018/07/16/upshot/costs-health-care-us.html
This is not accounted for in the JAMA study, which I am quite familiar with.
Please pay closer attention.
Now you’re just lying about what the article said. What the fuck? Allow me to quote the study itself:
Note even this guy doing his best to shift blame away from provider greed only manages to pin 10%-15% of the difference on providers’ inefficient administration.
The JAMA study asserts that the vast bulk of the difference in healthcare costs is attributed to outsized salaries compared to international peers, and outsized rates charged for medical procedures.
1. No, that is still. Not. What. I’m. Talking. About.
I don’t know why this is so hard for you to understand. A physician’s office may charge a certain amount for a service, but one of the costs they have to bear is a personnel cost for the many people in the office who have spend their full-time efforts dealing with all the approvals, prior authorizations, denials, appeals, etc, that are imposed on the providers by the insurance companies.
These administrative costs do NOT come under “planning regulating, and managing” because they are NOT on the insurer’s end, and they are NOT included in the figures quoted in that JAMA paper. But they still add to the price of services. That’s what the economist in the NY Times piece is talking about.
2. One of the biggest reasons physician salaries in other countries are lower than in the US is because MEDICAL SCHOOL IS FREE. Also, they almost all have 6 year programs, straight out of secondary school, so THEY DON’T EVEN GO TO COLLEGE, and THEY HAVE NO EDUCATIONAL DEBT WHATSOEVER.
Compare that to your average American physician, who has $170-180K in debt upon graduation (and is 2 years older, which equates to another $80-100K in lost income as an opportunity cost).
That’s not to mention that you spend your first 3-7 years out of school making ~$50K/year while all that debt continues to earn interest. You don’t even get to these salaries until you’re in your 30s, at which time you can start to pay down that massive financial boulder you’re carrying around.
But go on, please say more about inflated American salaries.
I have immense difficulty believing that’s true. I certainly won’t believe it in the absence of some pretty convincing evidence that it is. OTOH, I have seen reporting of polling results showing pluralities/majorities of Americans favoring single-payer or “Medicare-for-all” (i.e., essentially socialist, not private) solutions that don’t (or at least don’t necessarily) involve private insurance at all (or if at all, then only at the margins, e.g., the last 20% of costs).
What’s going on here? You wrote that in your own voice, Booman. Does that mean it’s your position, asserted on your “reportorial authority”? Or was that just you characterizing Williamson’s argument without making clear that this was not also your argument?
Without a vested interest in enriching oneself on what completely parasitic private insurance can skim off the top, no sane person would design a universal healthcare delivery system from scratch — from the ground up — to include that parasitic element. I’m no expert on the German/Swiss models, but my presumption is that a private insurance element is preserved in them for very similar reasons to why it got preserved in Obamacare: it was an existing, vested special interest with a powerful lobby and lots of political clout, including the ability to torpedo any proposal it found too threatening (see “Harry and Louise”, Clinton healthcare-reform initiative ’93-’94ish).
Continued survival (plus some relief in the form of subsidies of the cost of, e.g., hospitals treating the uninsured and having to write off the loss) was the price the industry extracted for not sinking Obamacare like they did “Clintoncare” (leaving only the Banana Republicans in unanimous obstruction mode). I even have some sympathy for the claim that this was the only way passage would ever have been politically doable. But it did come at high cost in efficiency, including cost-effectiveness. I find it hard to imagine anyone who’s both sane and honest claiming that we could not have as good or better universal healthcare at lower cost than at present (even with Obamacare in place) if the parasitic private health insurance industry were not guaranteed its cut, siphoned off the top.
Therefore, I am extremely skeptical that that quoted assertion above declaring “What Americans seem to want” is true. Unless, of course, “Americans” simply means “the Americans that matter to Williamson and Republicans”. Then, sure!
Martin, you nailed it.
You just left out one small piece of the dynamic: by actively UNDERMINING the ACA, and making it work less well, the GOP has increased people’s frustration with private insurance altogether, and increased the demand for single payer. So, they’ve not only boxed themselves in, they’ve actually fed demand for the competing product!
And the way this shakes out is that eventually, at some point, we will have a center-right party that is halfway sane — either a newly reconstructed GOP, or a new party that replaces them. By then the call for Medicare For All will be even louder, and that party will find its voice on this issue… as the staunch defenders of the ACA. Except that they will call it RomneyCare instead of ObamaCare. At that point we will finally have a legitimate health care debate in this country between 2 parties who are actually both interested in covering everyone in an economical fashion.
Now Canadians take their health care system for granted, but it wasn’t easy to get to where we are today.
Saskatchewan, where I live, was the first Canadian province to introduce Medicare in 1964 — there was a three-week doctors strike because of it, and a baby died before the strike collapsed. After that, it took at least 10 years for everyone in Canada to get onto roughly the same page regarding what services our health care system should actually provide and how they should be paid for. Our version of Medicare still doesn’t cover dental care, prescription drugs, physical therapy, or counselling, and there can still be disparities for people who move to a different province. Given that the United States is so much larger and more complex than Canada, its going to take you some time to get it sorted out too.
The reason why health care became such a salient issue in the mid-2000’s was because fewer employees accepted the health coverage from their workplaces, mostly due to high health costs. At the same time, public insurance declined due to welfare cuts. Because employer-based health care and Medicaid together didn’t lead to expanded coverage, one possible fix is to sever the link between health insurance and employment. That’s what the ACA exchanges were. (The ACA also expanded Medicaid; I believe most of the decline in uninsured came from Medicaid expansion).
The ACA was always the market-based solution. I honestly don’t know why Republicans want to return to the pre-ACA environment; the Essential Health Benefits are the new status quo. I continue to maintain that Republicans have no decent public policy proposals left: all they have is racism, cruelty, and tax cuts for the rich.
. . .
“High health costs” is problematic (how much does “health” cost? How high is “high”? What does it cost to be healthy? Can you pay enough to guarantee “health”? “Money can’t buy me [health]”. Sounds like it must be referring to the total cost of healthcare (e.g., during a given year). Which would be incentive, if anything, to accept employer-subsidized health insurance, not to decline it.
It appears from the Abstract at your link that what you really meant was “due to high health [insurance] costs” (which is not the same thing):
IOW, the cost of healthcare, and hence of health insurance, kept increasing steadily, but the proportion of health insurance cost being covered by employers declined (because either the amount the boss covered was reduced or stayed static; or it increased, but slower than the cost of the insurance); and so squeezed employees increasingly opted out.
From the small sample size of the crazy in my family, I would say that Republicans do not want healthcare for all at any level of care. They do not see health care as a right. This is such a values difference from the Democrats I know that it is practically a religious difference.
Yes, this is what truly animates them. The good news is that most people are not Republicans and find this point of view abhorrent, and it is politically costly. Maybe that cost lowers as people attach their vote on “values” more than their pocketbook, but when your values of “let them die in the street” become part in parcel with “I hate immigrants”, the two become interlinked anyway.