As we analyze the reprieve for Obamacare, let’s celebrate and make explicit the victory of facts over bluster, and substance over euphemism. Ryan was not honest about his real goals: massive tax cuts for the very rich and minimal restraint on the cruel effects of a deregulated health care marketplace. The Freedom Caucus was not honest about its goal: repealing Obamacare entirely, regardless of the harm inflicted on low income people. And few of the Republican moderates were honest about their belief: that Obamacare was doing a lot of good. (The moderates might well have become more vocal — if similarly obtuse — if the Freedom Caucus had softened and increased the chances of the bill making it through the House.) But the facts are that Americans don’t want to return to the days before Obamacare, and the Republicans’ internal divisions in this case do not lend themselves to workable compromise.  The moderates were unwilling to face their constituencies after voting for a law that would have made Obamacare worse for the average person. And the Freedom Caucus was unwilling to enshrine a new entitlement program under the Republicans’ watch. That is why Ryan gave up, rather than continuing to try to negotiate. Facts are stubborn things, but at least this time they mattered. 

We Americans typically think of insurance as a contract you buy to cover high-risk, low-probability events, such as car accidents, house fires, and premature death. Some aspects of health care fall into this traditional category, such as expensive emergency care for appendicitis or heart attacks. But most of us face these emergencies infrequently. Instead, the bulk of our medical care is for more routine or chronic ailments — relatively predictable, even if varying greatly in cost — such as high blood pressure, diabetes, and the flu. Yet we have come to expect our health “insurance” to cover most of the costs for all of these ailments, even though our home insurance doesn’t cover the broken furnace, rotting porch flooring, or decrepit wallpaper. Perhaps we should talk about “health care service contracts,” and perhaps if we did, we could have a more honest debate about what we expect from our health care system. Can market forces help keep costs down for all types of care or just for some? (Does anyone shop around for the most affordable ambulance or hospital while calling 911?) Can we bring back more limited health insurance policies for those who want them that cover only catastrophic events, or would that option destroy the economics of the broader system we’ve now come to expect?