As the Republican Party begins to define itself for the 2024 presidential campaign, its philosophy on health care is coming into focus: The government is not here to help you. But it should be allowed to get in your way.
Wednesday night's debate, which featured eight of the leading not-Donald-Trump candidates for the Republican nomination, spent little time on health care except for an extended exchange on abortion, covered in depth by Vox's Rachel Cohen.
But if you piece together the abortion debate with other moments in which health care briefly took the spotlight, the party's position on federal power in the medical sphere begins to take shape. On abortion, on health care for transgender people, even on mental health care, the candidates were comfortable flexing governmental authority to dictate the terms of medical treatment.
But when it comes to using that same authority to protect people during a global pandemic or providing health coverage to people with low incomes, they don't want the government getting involved.
How the GOP candidates want to use state power to restrict health care
Abortion — which Fox moderator Martha MacCallum cast as a "losing" political issue for Republicans ever since the Supreme Court overturned Roe v. Wade — led to a contentious exchange in which former South Carolina Gov. Nikki Haley urged her fellow candidates to be square with GOP voters: It will be difficult to pass a national abortion ban given the political realities of the US Senate.
Haley was largely an outlier, though North Dakota Gov. Doug Burgum also argued the issue would be rightfully left to the states under the 10th Amendment. Former Vice President Mike Pence and US Sen. Tim Scott of South Carolina made impassioned pleas for a 15-week national abortion ban. Scott argued that the decision on abortion policy should be taken away from the states — the elected representatives who are closest to the pregnant people affected and who conservatives have traditionally argued should make these decisions — because they cannot be trusted to set these standards on their own.
"We cannot let states like California, New York, and Illinois have abortions on-demand up until the day of birth. That is immoral. It is unethical. It is wrong," Scott said to applause from the audience of Republican primary voters. (For the record, fact-checkers have repeatedly corrected Republicans for making similar claims in the past and only 1 percent of abortions occur after 21 weeks of gestation.)
"We must have a president of the United States who will advocate and fight for at the minimum a 15-week limit," Scott continued.
The entire premise of the anti-abortion movement is to involve the state in a life-altering medical decision otherwise handled privately between a doctor and a patient. In spite of the evidence of the economic and health consequences of restricting abortion and in spite of the political losses the GOP has incurred since the Supreme Court negated the right to privacy enshrined in Roe, Scott and others reaffirmed a commitment to keeping the state in that position. The crowd roared.
Transgender rights and the myriad conservative laws passed in the past few years to restrict access to gender-affirming care were referenced only obliquely in the debate but carried the same message. Florida Gov. Ron DeSantis touted his record of "eliminat[ing] gender ideology from our K-12 schools." North Dakota Gov. Doug Burgum defended his signing of a bill that banned certain students from participating in school sports. In his closing remarks, Scott pledged that "if God made you a man, you play sports against men."
As Katelyn Burns wrote for Vox in 2021, medicine itself has undergone a transformation on the subject of gender diversity and gender-affirming care. Historically, people who identified as a different gender than they were assigned at birth were viewed as having a disorder that needed to be fixed. More recently, most doctors have come to believe that such patients should be handled more humanely and affirmatively; permitting them to make a social gender transition (changing their name and pronouns, using a different bathroom, etc.) is treated as a given. Medical interventions for young people are to be taken on a case-by-case basis.
But as the GOP candidates' comments at the debate made clear, they have little interest in permitting even a social transition for transgender youth. And in statehouses across the US, the party has sought to restrict this kind of medical care as much as possible.
"Trans advocates have pointed out that these bills fit comfortably within the larger GOP plan to seize minority power in an effort to force their preferred gender dynamics," Burns wrote. The state, not the individual nor their doctor, is dictating the terms of health care.
In one of the most striking tangents of the night, businessman Vivek Ramaswamy even advocated for reopening "mental health institutions" that have closed over the decades as the country sought to cut costs (starting in the Reagan administration) and tried — but has largely failed — to invest in more humane home- and community-based services. He framed putting more people with mental health problems into those institutions as one of the most important ways to address crime.
"Just over the same period that we have closed mental health institutions, we have seen a spike in violent crime. Do we have the spine to bring them back?" he said. "I think we should. As president, I will."
I have interviewed people who were subjected to the cruel treatment that was often commonplace in the mental health asylums of old. The new mental health paradigm is focused much more on treating people where they are. While the US has struggled to erect a sufficient mental health system given the scale of the country's needs, few people who work in the field would argue that a return to the institutions of that era is the recipe for fixing our mental health crisis.
But Ramaswamy, the biggest non-Trump sensation of the GOP primary so far, does. He even implicitly allowed that "drugging up people in those psychiatric institutions with Zoloft and Seroquel" would be part of the program (but not the only part; he also wants a return to the patriotism, faith, and family that he believes constitutes the American character).
It demonstrated an astonishing willingness to use the power of the state to interfere with the ability of certain people, particularly the historically marginalized, to achieve health and well-being — a consistent theme of the night.
Republicans still don't want the government to help people get health care
What affirmative actions the candidates might take to improve people's health was generally neglected in the first debate of the 2024 campaign. No candidate laid out a health care reform agenda, as Republicans are still in the health policy wilderness after their failure to repeal and replace the Affordable Care Act.
But a few select moments revealed that GOP candidates, while perfectly comfortable interfering with certain medical decisions, remain opposed to using that same government authority to provide assistance to people who need access to health care or to protect people whose health may be at risk in a public health emergency. They will still cling to the veneer of small government and individual liberty in certain contexts.
The most obvious such moment is when DeSantis took a line of questioning about the economy and touted his willingness to shirk the public health consensus on Covid-19.
"Why are we in this mess? A major reason is because how this federal government handled Covid-19 by locking down this economy. It was a mistake. It should have never happened," he said. "In Florida, we led the country out of lockdown. We kept our state free and open. And I can tell you this: As your president, I will never let the deep state bureaucrats lock you down."
DeSantis's pandemic record is complicated and I covered it in depth earlier this year. In brief, yes, the state enjoyed an earlier economic recovery as pandemic restrictions were sunset, but it also had a middling performance in terms of health outcomes. DeSantis also pushed beyond ending lockdowns to embrace vaccine skepticism, including empowering a vaccine skeptic as his state surgeon general. Experts who saw the administration's response up close believe DeSantis's about-face was detrimental to the health of his state's citizens — and believe it was more politically calculated than anything else.
But a governor who signed a six-week abortion ban and a ban on gender-affirming care for minors while placing new requirements on such care for adults, putting the state firmly in the middle of individual medical decisions, was proudly unwilling to use the same power to try to tame the spread of a virus that ultimately killed more than 1 million Americans including 80,000 Floridians.
One other brief moment, on another subject, reinforced the same ideas. As Haley tried to take Republicans to task for their role in increasing government spending in recent years, she mentioned the increase in Medicaid enrollment that followed the institution of an emergency policy that allowed people to stay on the program's rolls.
"Our Republicans did this to us too. When they passed that $2.2 trillion Covid stimulus bill, they left us with 90 million people on Medicaid, 42 million people on food stamps" she said. "No one has told you how to fix it. I'll tell you how to fix it. They need to stop the spending."
Her meaning was clear: It was a problem that so many people enjoyed government benefits and didn't need to worry about their health coverage, even during the pandemic. As it happens, the government is unwinding that emergency policy — and millions of Americans are losing their health insurance as a result.
Nobody asked the Republican candidates about what they might do to address the dramatic increase in the uninsured rate that will result. As Wednesday night's debate made clear, they don't think of that as the government's job.
But if you are a certain kind of person who needs a certain kind of treatment, they are ready and willing to put the state between you and your health care.
